Inspection on 01/08/05 for Elmridge Nursing Home

This inspection was carried out on 1st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Elmridge Nursing Home 15/03/07

Elmridge Nursing Home 12/12/05

Elmridge Nursing Home 11/11/04

Elmridge Nursing Home 21/06/04

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

CARE HOME ADULTS 18-65 Elmridge Nursing Home The Pastures Coulby Newham Middlesbrough TS8 0UJ Lead Inspector Val Daly Unannounced 1 August 2005 09:30 am 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. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Elmridge Nursing Home Address The Pastures, Coulby Newham, Middlesbrough. TS8 0UJ 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) 01642 590028 BUPA (Goldsborough) Ltd Mrs Helen Elizabeth Saunders Care Home 42 Category(ies) of LD(E) Learning Disability - Over 65 (20), registration, with number LD Learning Disabilty (22)) of places Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The home can only accommodate up to 20 elderly service users (65 ) with a learning disability LD (E). Date of last inspection 11/11/2004 Brief Description of the Service: Elmridge Nursing Home is a 42 bedded care home with nursing, registered under the Care Standards Act 2000 to provide care to 42 adults with learning disabilities. The home has conditions of registration in place to enable it to provide care to 22 people with learning disabilities aged between 18 and 65 and no more than 20 people with learning disabilities aged over 65. The home was first registered under the Registered Homes Act 1984 in 1993. The registered provider is BUPA (Goldsborough) Ltd. The responsible individual is Mrs L Tart and the manager is Mrs Helen Saunders. Elmridge is a single storey building divided in 4 units with each of these areas opening into a large room used for day activities. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 9.30am and lasted for four hours. The manager, qualified staff and the administrator were spoken to during the inspection. Numerous records including care assessments, care plans and maintenance records were examined. A tour of the premises was carried out What the service does well: What has improved since the last inspection? 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. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 6 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 Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 7 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) 2 The homes assessment documentation is not always fully completed. EVIDENCE: The twenty- four hour life plans from two out of the three care plans examined were incomplete and did not show that individual needs and aspirations of residents were fully assessed. For one resident the risk assessment tool should have been completed monthly. Records showed that this had not been carried out since May 2005. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 8 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) 9 Residents are supported to take risks within a risk management framework. EVIDENCE: Documentation in resident’s files showed that risk assessments were in place where needed to encourage an independent lifestyle. Staff support the residents and for one person an advocate was involved to assist towards independent living. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 9 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) 12, 13 & 15 Residents are provided with a range of activities within the home and local community. EVIDENCE: Residents take part in many activities in the home, the local community and outings. There had recently been an educational display from the ‘Zoo Lab’. Reptiles and small animals were brought into the home for the residents to touch or just watch, whichever they felt more comfortable doing. Prior to the inspection residents had enjoyed a day out at Hartlepool Marina and a visit to see the tall ships at Newcastle. Local events are also well attended by the residents. There are in house activities such as arts, crafts, a sensory room is available and the home had recently purchased a ball pool. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 10 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) 20 Good systems for storing and administering resident’s medication are in place. EVIDENCE: The home has a system for storing, administering and recording of medication. Records of medication received at the home, given to residents and returned to the pharmacy were seen to be accurate. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 11 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) EVIDENCE: These two standards were not assessed at this inspection. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 12 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) 24, 25 & 30 EVIDENCE: A tour of the home was carried out. Residents appeared comfortable in their various lounges. Maintenance audits in the home are carried out on a regular basis, which was evidenced in the maintenance records. Residents’ bedrooms are individually decorated and furniture arranged to promote independence. In the majority of the bedrooms the curtains were not hung properly, some had missing curtain hooks and tab topped curtains were not hung on poles. Many of the curtains were of poor quality. Window blinds were damaged in two of the bedrooms and required replacing. In the communal areas many doors and walls were damaged due to hoists being manoeuvred around the home. In one bedroom copper pipe needed to be boxed in. The home was odorous in many of the communal areas. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 13 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) 35 & 36 The staff team have worked hard to ensure that in excess of 50 of them are qualified to NVQ level 2 in care. Staff receive regular supervision. EVIDENCE: Staff training records showed that more than 50 of care staff have achieved NVQ level 2. Training is ongoing in First Aid with the qualified staff recently completing a four-day course. A formal supervision system is in place and staff supervisions were up to date. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 14 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 Required policies and procedures are in place. Training for some staff is overdue. EVIDENCE: The home has health and safety policies and procedures in place and checks are undertaken regularly. However it was noted that staff training in health and safety and COSHH was required. A certificate was not available for the five yearly periodical installation tests and an immediate requirement notice was issued. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 15 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 x 2 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elmridge Nursing Home Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 16 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. 2. 3. 4. 5. Standard 24 25 30 42 42 Regulation 23 (2) (b) 16 ( c) 16 (k) 18 ( c) (i) 12 (1) (a) Requirement Damage to walls and around doors in communal areas must be repaired. Adequate curtains/window dressings must be provided in residents bedrooms. The home must be kept free from odours Staff must receive training in Health & Safety and COSSH Maintainance certifcates must be satisfactory, up to date and available for inspection. Timescale for action September 30th 2005 September 30th 2005 30th September 2005 30th September 2005 30th September 2005 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. Refer to Standard 3 Good Practice Recommendations Assessment documentation needs to be fully completed. Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection Unit B - Advance St Marks Court Teesdale Stockton-on-Tees. TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elmridge Nursing Home B51-B01 SN165 Elmridge VN241050 010805 Stage 4.doc Version 1.40 Page 18 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!