Inspection on 02/08/05 for Elms Park Care Home

This inspection was carried out on 2nd 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

Elms Park Care Home 24/04/07

Elms Park Care Home 20/04/06

Elms Park Care Home 14/12/05

Elms Park Care Home 09/03/05

Elms Park Care Home 13/04/04

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 Elms Park Care Home 11 Elms Park Ruddington Nottingham NG11 6NU Lead Inspector Meryl Bailey Unannounced 2 August 2005 at 10:00 am nd 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. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Elms Park Care Home Address 11 Elms Park Ruddington Nottingham NG11 6NU 0115 9456323 0115 9456323 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) Ms Janine Tregelles Mr Jason Fennell Care Home (CRH) 8 - (Eight) Category(ies) of Learning disability (LD) - 8 (Eight) registration, with number of places Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2005 Brief Description of the Service: Elms Park is a care home providing personal care and accommodation for up to 8 adults with a learning disability. Care and support is provided by Mencap, though the building is owned by Nottingham Community Housing Association. The home is located in the village of Ruddington with easy access to the village centre. All bedrooms are single and on the ground and first floor. There is no lift, but the ground floor has level access. There is a garden to the rear of the house, which has seating for service users. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and conducted by one inspector during one morning. Most service users were seen boarding a bus to go to day activities at the commencement of the inspection and were not able to contribute their views. Two staff were seen and their comments and views have been incorporated into this report. Information has also been taken from records as well as a recent questionnaire completed by the manager. The communal areas of the home were inspected, but only one bedroom was viewed on this occasion. 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. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 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 Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 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 Needs have been assessed prior to admission. EVIDENCE: Appropriate pre admission assessments were seen on the three files examined. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 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) 6 and 9 Actions required to meet needs and personal goals are described in Individual Support Plans, but some updating is required. Risks are assessed and efforts made to minimise the risks identified, whilst support is given to develop and maintain independence. EVIDENCE: The files of three service users were inspected and contained relevant details. Individual Support Plans were not readily available for inspection as they are stored on computer and the only printed copies are held in service users’ own rooms. One was provided and examined and was found comprehensive, covering all aspects of daily living. However, information relating to changes in needs had implications for the plan, but relevant sections had not been updated. The service user has awareness of the plan and staff reported that some service users are very involved and possessive about their individual plans. It is recommended that copies of the Individual Support Plans be kept with the personal files for immediate staff reference. Risk assessments are contained in the personal files and cover individual activities. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 9 For example, all service users are encouraged to cook their own meals and have been assessed for risks in the kitchen. As some activities need 1:1 supervision there are implications for staffing levels (see under standard 33). It is further recommended that, where needs are frequently changing, the support plan be reviewed at least monthly to ensure needs are met. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 17 Service users are encouraged and enabled to take part in appropriate activities. Meals are individually prepared and a healthy, balanced diet is encouraged. EVIDENCE: Staff stated that one service user does voluntary work and another has paid employment on a part time basis. All the service users have some form of daily activity for most of the week including day centres and attendance on educational courses. Records of review meetings regarding day services were contained on the personal files. There were records of meals that are individually cooked by service users with varying amounts of staff support and supervision. Records show a range of fresh, frozen and chilled foods used and fresh fruit was seen available in the dining room. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 20 Preferences with respect to personal care and support are detailed in Personal Support Plans. Medication is held securely for service users, but some reorganisation is needed to prevent the risk of errors. EVIDENCE: Just one service user needs personal care and support in relation to his changing needs, but most others need encouragement, prompting and supervision. The design of the Individual Support Plans gives full opportunity for service users to describe how they would prefer support or supervision to be given. Medication is held securely in a locked cupboard for those who need it. Homely remedies are included with prescribed medication. A full pack of aspirin was found, and, as this is not on the list of safe homely remedies the staff member present immediately removed it. There were some records of homely remedies administered, but it is recommended that individual sheets for each service users be kept with Medicine Administration Record sheets so that all staff are fully aware of what has been administered. Storage could be better organised, by separating medication for each service user within the cupboard. Three bottles of olive oil were not clearly labelled with names or when to be administered, initials only were barely readable. Other prescribed medications in tablet form were in dosage boxes and were well recorded on the Medicine Administration Sheets. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 12 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) These standards have not been fully assessed on this inspection. EVIDENCE: Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 13 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, 26 and 30 A well-maintained, comfortable environment is provided and individual rooms promote independence, though do not contain all minimum standard facilities. The home is clean throughout. EVIDENCE: All communal areas were seen and bathrooms, but just one bedroom was seen. The lounge and dining room are comfortable and homely. All areas were found to be very clean and well maintained. The laundry room was well equipped and there was a rota for most service users to do their own washing. The garden is extremely well tended, with a pleasant seating area. Since the last inspection, the ground floor bathroom has been re-tiled and decorated, with new flooring and the first floor shower has been replaced. There are fire escapes from the first floor, but these are not alarmed (see standard 42). Bedrooms are lockable and most service users keep their own key. None of the bedrooms have washbasins, but bathrooms are close to bedrooms. The bedroom seen was generally suitable for the individual, but there was no call alarm system, and it is recommended that the need for this facility be assessed, particularly as there is only one staff member at night, who is asleep. For at least one service user an alarmed pressure mat may be suitable to alert the staff. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 14 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) 33 Staffing levels are being determined by staff availability rather than the needs of service users, resulting in needs not being immediately met and putting service users at risk. EVIDENCE: The support worker on duty worked alone with eight service users from 6pm on 1st August 2005 until 9.20 am on 2nd August 2005, sleeping in on the premises. This worker said that this was because no one else was available after 6pm. There were other similar examples of long hours of lone working shown on the current staffing rota. According to this rota, evening shifts are planned to continue to 8 or 9pm and morning shifts should commence at 7am. There is never any more than one staff person during the night, as needs are low during the night. Staff had made changes in the rota, which resulted in staffing levels being determined by staff availability rather than need. Records show one lone worker had been involved in providing personal care to one service user for two and a half hours on a Saturday morning recently. This posed a health risk to another service user using a bathroom and there were others who had to wait for assistance. One service user has been assessed as needing specific 1:1 support at specific times during the evening, but staff were not always available to meet this need. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 15 An immediate requirement was made for Mencap to demonstrate how staff hours have been calculated and how staffing was organised to meet the needs of all current service users at all times. A blank proposed rota submitted to the Commission shows two staff working from 7am and 10pm, but rotas completed with staff names do not cover all these hours. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 16 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 Attention has been given to health and safety generally, but further risks should be assessed and action should be taken for safety and security. EVIDENCE: Staff reported having had training in safe working practices, including Health & Safety, First Aid and Basic Food Hygiene. All windows in bedrooms had appropriate restricted openings for safety, but the lounge window opened wide and should be restricted as a security precaution. A fire log was kept up to date with weekly checks on alarms and at least two full evacuations each year. All fire extinguishers were checked in June 2005. However, there are fire exit doors on both floors and it is recommended that alarms be fitted to these to alert staff if they are opened, particularly at night. There was no written risk assessment about this. As stated under standard 26, further alarm systems would alert staff to movement around the premises during the night. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 17 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 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x 3 Standard No 31 32 33 34 35 36 Score x x 1 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elms Park Care Home Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA 6 YA 20 YA 33 Regulation 15(2) 13(2) 18(1)(a) Requirement Individual Support Plans must be kept under review and updated as needs change. Remove non prescribed aspirin from the medication cupboard. Completed. Demonstrate how staff hours have been calculated and how staffing is organised to meet the needs of all current service users at all times. Timescale for action 31st August 2005 2nd August 2005 11.55am Immediate 16th August 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. 2. 3. 4. Refer to Standard YA 6 YA 6 YA 20 YA 20 Good Practice Recommendations Keep copies of the Individual Support Plans with the personal files for immediate staff reference. Where needs are frequently changing, the support plan should be reviewed at least monthly to ensure needs are met. Record any homely remedies administered on individual record sheets. Separate medicines for each service user within the storage cupboard. C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 19 Elms Park Care Home 5. 6. 7. 8. YA 20 YA 26 YA 42 YA 42 Ensure all medication is clearly labelled with full names and instructions. Assess the need for a call alarm system including pressure mat alarms. Restrict the opening of the lounge window for added security. Assess risks associated with fire exits and fit warning alarms as appropriate. Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Edegley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elms Park Care Home C53 C03 S8672 Elms Park V242342 020805 Stage 4.doc Version 1.40 Page 21 - 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. 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