Inspection on 15/03/07 for Elmridge Nursing Home

This inspection was carried out on 15th March 2007.

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

Elmridge Nursing Home 12/12/05

Elmridge Nursing Home 01/08/05

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 Key Unannounced Inspection 15th March 2007 09:30 Elmridge Nursing Home DS0000000165.V332073.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 Elmridge Nursing Home DS0000000165.V332073.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. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmridge Nursing Home Address The Pastures Coulby Newham Middlesbrough TS8 0UJ 01642 590028 01642 576384 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) www.bupa.co.uk BUPA Care Homes (GL) Ltd Mrs Helen Elizabeth Saunders Care Home 42 Category(ies) of Learning disability (22), Learning disability over registration, with number 65 years of age (20) of places Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can only accommodate up to 20 elderly service users (65 ) with a learning disability LD(E). The home can accommodate one named service user under the age of 25. 12th December 2005 Date of last inspection 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 DS0000000165.V332073.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and was completed by one inspector and a regulation manager over one day. At the time of the inspection the manager was on sick leave, and the information and the deputy manager provided the information and documentation required. As a key inspection, all of the key standards were examined. A tour of the home took place, resident’s records were examined, records including accidents, complaints and menus were looked at and staff, the deputy manager and area manager were engaged in discussion about life at Elmridge. What the service does well: The home employs two activity co-ordinators and one assistant. They organise activities both in house and in the local community. Hours worked are usually nine am until five pm but there is flexibility if activities are in the evening. There is a guide of weekly activities and a calendar to inform residents and relatives of activities. One of the activity organisers works in the home along with carers. In house activities include quizzes, bingo, crafts, and art. Each month there is an event for charity, one event being sampling teas and cakes, which had been donated by ‘Betty’s Tea Shop’. The other activity organiser takes residents out on the minibus; trips out are very popular either to a specific place such as a show at The Arena in Newcastle, a trip to Redcar, Whitby or just as a change of scenery. Each resident has an activity profile, which includes his or her likes/dislikes and experiences. Three of the residents attend day centres where a variety of activities take place. The home undertakes regular audits, with action plans of the service they provide. These include monthly audits of complaints, pressure sores, accidents and regulation 26 visits from the area manager. There are also regular clinical forums held in the home where qualified staff can discuss any areas of concern and undertake training with the area manager. Outcomes of audits are also talked about within these meetings. The manager has been in post for many years as have the majority of the staff. This ensures a consistent approach with the residents and staffs are aware of their individual needs and wishes. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Elmridge Nursing Home DS0000000165.V332073.R01.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 Elmridge Nursing Home DS0000000165.V332073.R01.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident’s care needs are assessed prior to the move to the home, and periodically thereafter. This will help ensure that each resident’s needs are met at the home and inappropriate admissions avoided. EVIDENCE: Three residents files were examined and they both contained a full detailed assessment of needs: moving and handling, falls, nutrition, weight. Further assessments are carried out on a regular basis and include the resident, where appropriate, qualified nurse and key worker. Elmridge Nursing Home DS0000000165.V332073.R01.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): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take risks within a risk management framework. This helps to ensure they remain safe and that their independence is promoted. EVIDENCE: Three sets of documentation were examined; they each contained a 24-hour life plan, giving a picture of a day in the life of the resident. Activity profiles were also included. The information was comprehensive and easy to read. Within the documentation examined, risk assessments were in place for falls, use of cot sides, use of a wheelchair, depending on the resident’s individual needs. Equality and diversity issues were highlighted in the care plans in respect of sexuality and religion. A qualified nurse, team leader and carer formulate care plans. Residents are involved with their plans of care as far as they are able. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their life style. Social and recreational activities meet individual’s expectations. EVIDENCE: The home employs two activity co-ordinators and one assistant. They organise activities both in house and in the local community. Hours worked are usually nine am until five pm but there is flexibility if activities are in the evening. There is a guide of weekly activities and a calendar to inform residents and relatives of activities. One of the activity organisers works in the home along with carers. In house activities include quizzes, bingo, crafts, and art. Each month there is an event for charity, one event being sampling teas and cakes, which had been donated by ‘Betty’s Tea Shop’. The other activity organiser takes residents out on the minibus; trips out are very popular either to a specific place such as a show at The Arena in Newcastle, a trip to Redcar, Whitby or just as a change of scenery. Each resident has an activity profile, which includes his or her likes/dislikes and experiences. Three of the residents attend day centres where a variety of activities take place. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 11 Menus showed a variety of food is offered and staffs completes the choices with the residents where they are able to do so. Generally staff know what residents likes to eat, pictorial menus are in the process of being formulated. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 12 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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The care plans examined detailed the personal support needed and given. All residents in the home have their own General Practitioner. The consultant visits the home and carries out reviews of resident’s condition, behaviours, epilepsy, medication, protocols and procedures. Each resident receives support from staff to the level that they choose and require. Policies and procedures are in place for the ordering, receipt, storage, disposal and administration of medication. Examination of medication administration records and storage of medication showed that the procedures were being followed. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 13 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: The home has a complaints procedure and policy in place. There had not been any complaints made to the home since the previous inspection. A monthly analysis form is completed for any complaints made. Staff work closely with the residents and relatives to ensure any concerns or grumbles are dealt with straight away. The home has an adult protection policy and procedure in place, staffs training files examined showed that training in ‘No Secrets’, the protection of vulnerable adults had been completed. Staff interviewed confirmed they had received the training. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 14 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment. EVIDENCE: All areas of the home were comfortable, safe and generally well maintained. Resident’s bedrooms are individually decorated and furnished to suit their needs and wishes. The bedrooms in one of the units did not contain any ornaments or nick knacks, this was due to the disability of the residents Instead there was more bold colours with fabric and paint. In two of the units there was wall damage in two corridors. This was due to wheelchairs and hoists. The home was clean without any odours. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 15 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, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffs in the home are trained, skilled and insufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The home has recruitment policies and procedures in place. Four staff files were examined and whilst the required checks were made there was not sufficient information in the individual curriculum vitae’s regarding the dates of previous employment. Interview questions and answers were also not included within the files, which is part of the home’s employment process. ] On commencement of employment each member of staff is given an induction booklet, which they work through with a mentor. The booklet has six sections with videos and questions and the induction process can take up to six months. At the end of this the member of staff is then two thirds of the way through their NVQ level 3. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 16 Staff training files were examined which showed training had been carried out in Food Hygiene, ‘No Secrets’, Infection Control, First Aid, Fire Training, epilepsy and dementia awareness. At the time of the inspection twenty carers out of twenty- seven had achieved NVQ level 2 or above. Domestic staffs have also completed NVQ level 2 in support care. Two members of staff interviewed clearly enjoyed their job and felt the training, support and supervision was good. The home has a formal supervision system in place with staff receiving supervision every eight weeks. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 17 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance developed by the provider. EVIDENCE: The home undertakes regular audits, with action plans of the service they provide. These include monthly audits of complaints, pressure sores, accidents and regulation 26 visits from the area manager. There are also regular clinical forums held in the home where qualified staff can discuss any areas of concern and undertake training with the area manager. Outcomes of audits are also talked about within these meetings. Staff meetings are held, both within the units and as a large team. The manager is also available to speak with residents and staff on a daily basis. The home has health and safety policies and procedures in place. Training files showed that staff has received training in health and safety. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 18 Residents receive good support from staff to ensure that their personal, physical and emotional health needs are met. The manager has been in post for many years as have the majority of the staff. This ensures a consistent approach with the residents and staffs are aware of their individual needs and wishes. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 3 3 X 3 X 3 X X 3 X Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action 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 YA34 Good Practice Recommendations Within staff files, more information in the individual curriculum vitae’s regarding the dates of previous employment is needed. Interview questions and answers should be included within the files, which is part of the home’s employment process. This will ensure the recruitment process protects people who use the service. Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Elmridge Nursing Home DS0000000165.V332073.R01.S.doc Version 5.2 Page 22 - 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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