Inspection on 20/04/06 for Elms Park Care Home

This inspection was carried out on 20th April 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elms Park Care Home 24/04/07

Elms Park Care Home 14/12/05

Elms Park Care Home 02/08/05

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 Inspection 20th April 2006 02:00 Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 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 Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 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. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elms Park Care Home Address 11 Elms Park Ruddington Nottingham NG11 6NU 0115 945 6323 0115 945 6323 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.mencap.org.uk Royal Mencap Society Wendy Cynthia Warner Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the total number of beds, a maximum of 8 (eight) may be used for the category LD 14th December 2005 Date of last inspection 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. Fees are dependent on individual needs and funding arrangements through the local authority. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information from people who use services aswell as staff and providers. Records of information received since the last inspection have been used together with an unannounced inspection visit to the home, which lasted four and a half hours. Discussions were held with service users and staff about their views of the service provided. The manager was not present during the visit, but further discussions were held with her by telephone a few days later. Some of the care records were examined to assess how care is planned. There was also a tour of the building and some direct observation of support given by staff. Six service users were at home for part or all of the visit and a total of four support staff were seen. What the service does well: What has improved since the last inspection? What they could do better: The records did not clearly show if all parts of individual support plans were reviewed and the manager should clarify the system of reviewing plans. There had been a recent error made with medication so that one person did not receive a tablet that was regularly prescribed. Staff must be able to administer medication accurately. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 6 No complaints had been recorded under the complaints procedure, but at least one service user had made a complaint about lost clothing. The manager must ensure all complaints are fully investigated and keep a record of the action taken and the outcome. Although there had been some improvement in the number of staff during the day there was still a gap of one hour during this inspection when there was only one member of staff with five service users in the home. There must be sufficient staff to meet the needs of all service users at all times to avoid risks to safety. There is only one staff member on duty during the night and this person sleeps in the office. One service user had used a mobile phone to summons help during the night. It is recommended that a call alarm system be made available to all service users. 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 DS0000008672.V289582.R01.S.doc Version 5.1 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 Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. Needs are assessed prior to any prospective service users moving into Elms Park. EVIDENCE: There had been no new service users since the last inspection and there was one vacancy. Appropriate pre admission assessments were seen on the three files examined. Staff reported that careful consideration was being given to filling the vacancy. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 Quality in this outcome area is adequate. Individual plans are created with service users to agree the support required. However, the review system is not clearly recorded and does not guarantee all needs for support are reviewed. Service users are supported to be as independent with some assessed risk taking. EVIDENCE: The individual plans and files of three service users were examined. They were comprehensive with details of the support required to meet needs. There were some relevant risk assessments linked with planning support. It was clear from these that service users were supported to take some risks in, for example, preparing meals and travelling independently. One service user gave information about being trained by a support worker in independent travel. All staff had signed sheets to show that they had read the plans. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 10 Each of the service users had a copy of their own individual support plan and additional financial plan within their own room. One spoken with was fully aware of the content and had signed agreements. There was evidence that the plans were being reviewed, but the system and recording of reviewing was not clear. There were some written notes of monthly reviews between service users and their key workers. There were also indications that risk assessments were reviewed on a three or six monthly basis, but there was no clear link between these and monthly reviews and no assurance that every need area of the support plans had been fully reviewed. The manager should clarify the reviewing system. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15,16, and 17 Quality in this outcome area is excellent. Service users take part in a wide range of activities and have developed their own preferred lifestyles. Healthy varied diets are encouraged. EVIDENCE: Various discussions were held with five of the service users during this inspection and they gave information about various activities and their individual lifestyles. The service users used local shopping and library facilities within Ruddington. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 12 One service user did voluntary work and another has paid employment on a part time basis. All the service users had some form of daily activity for most of the week including day centres and attendance on educational courses. Service users said that they visited friends for tea and friends visited the home. They all spent Christmas and some weekends with families. There was evidence of visits from family members and friends in the record of visitors to the home. There was evidence in records of the involvement of advocacy groups and service users reported receiving training related to their rights. One service user had been trained to be part of staff interviewing panels. There were records of meals that were individually cooked by service users with varying amounts of staff support and supervision. Records showed a range of fresh, frozen and chilled foods used and canned, fresh, chilled and frozen food stocks were seen available. These were kept separately for each service user, with lockable facilities in the kitchen and separate boxes and trays in the refrigerators and freezer. One support worker had undertaken a healthy eating session with the service users and more were planned. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. Service users are involved in specifying the support they require with their personal care. Staff support service users to access health services. Medication is generally well organised, but storage is cramped and the current administration by tired staff could give rise to errors. EVIDENCE: Service users held their own individual support plans in their rooms. Most were totally independent in their personal care, and some required some supervision and encouragement. This was specified in the plans seen. There were records of contacts with health professionals and details of advice and guidance to be followed. Service users gave information that showed they were supported to access health advice, guidance and treatment. All medication was held securely in a small locked cupboard on behalf of service users. Storage would be improved by providing a larger cupboard. Medicine Administration Record sheets were maintained, but there were clear omissions in signing for medication on one morning of the current week. On checking the dosage system packaging all tablets had been removed for that Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 14 day. A member of staff reported that she had noticed the lack of signature and, on investigating; one person had not received some medication. She had removed the tablet from the package and stored it safely for return to the pharmacist. A message had been left for the manager about the error to be dealt with on return to work the following week. It was the role of the “sleep in” staff member to administer morning medication. It is recommended that this be changed, as this person will have been on duty since 2pm the previous day. The responsibility for medication would be more appropriately given to a staff member arriving fresh on duty. This was discussed with the manager by telephone following the inspection visit. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 22 and 23 Quality in this outcome area is good. Service users concerns are listened to, but not all complaints are fully recorded. Service users are protected from abuse. EVIDENCE: The complaints procedure was displayed appropriately in the dining room. Service users said that they speak to key workers when they have any concerns. There were no formally recorded complaints and none had been received at the Commission. There was, though, reference to a complaint about missing clothes in one service user’s running records. There was no clear indication of the final outcome and it is required that such complaints be recorded in full with details of action taken and their eventual outcomes. There was a copy of the Nottinghamshire Committee for the Protection of Vulnerable Adults policy and procedures, which was available to staff. There Formal risk assessments gave appropriate action taken to minimise risks and protect service users from harm and service users had been given selfprotection training. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 24, 26 and 30 Quality in this outcome area is good. Service users share a homely environment, with individualised bedrooms and all areas are generally clean, though some attention to maintenance is needed. EVIDENCE: All communal areas and bathrooms were seen, together with three of the bedrooms. The lounge and dining room were comfortable and homely. All areas were found to be very clean, but some areas were in need of attention, for example, some wallpaper was pealing off in the lounge and flooring was damaged in a first floor bathroom. Bathrooms were otherwise appropriate to suit the needs of the current service users, some of whom said they had the choice of bath or shower. The laundry room was well equipped and there was a rota for service users to do their own washing. The bedrooms were individualised, but there were still no individual call alarm system (see under standard 42). Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. The recruitment procedure protects service users and staff are trained. There are usually sufficient staff provided to meet needs, but even short periods of staff shortages could put service users at risk. EVIDENCE: Service users spoken with were clear about the roles of support staff and instantly knew who their key worker was. Positive interactions between service users and staff were observed. Staffing rotas showed an improvement since the previous inspection in the provision of sufficient staff. There was an exception of one hour during this inspection visit, when only one member of staff was present with five service users during the afternoon. Otherwise, there were always at least two staff available from 8am to 10 pm and one staff asleep over night. Staff reported that night time needs were very low and service users were usually in their own rooms throughout the night. This was supported by the individual plans seen. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 18 All staff had received Foundation Training with Mencap. This was comprehensive and accredited within the Learning Disability Award Framework. Three staff were pursuing Training at level 2 of the National Vocational Qualification in Care. Staff had all been fully checked prior to working in the home. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. The home is well run and the manager is supported in her role. Service users are encouraged to be involved in the running of the home and safety is promoted. EVIDENCE: The manager has been registered with the Commission. She was not present for this inspection, but has supplied some additional information regarding training. She had almost completed the National Vocational Qualification level 3 in Care and was progressing to level 4. Further management mentoring was provided to develop her management skills and knowledge. During the inspection visit, there was clear evidence of the use of Mencap’s policies and procedures in the running of the home. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 20 The service was monitored by an area manager who supplied the Commission with regular reports of visits to the home. There were regular house meetings held and service users were discussing the agenda for the meeting to be held during the evening after this inspection visit. One of the support staff reported that up to date training in safe Moving and Handling was given to five staff at the beginning of April 2006, by the St John Ambulance service. Records supplied showed that all staff had been trained in other safe working practices, including Health & Safety, First Aid and Basic Food Hygiene. 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. There were movement detectors in place at night in the various areas of the home, which activated an alarm in the office where staff slept. However, there were still no effective individual call alarms for service users to alert sleeping staff from their room. One service user had used her mobile phone for this purpose when feeling ill on one occasion. Not all service users have that facility. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 21 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 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 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13(2) Requirement The registered person must make arrangements for the recording, and safe administration of medicines by ensuring staff are able to carry out these tasks accurately. The registered person must ensure all complaints are fully investigated under the complaints procedure and keep a record of the action taken and the outcome. The registered person must ensure there are sufficient staff to meet the needs of all service users at all times. Timescale for action 27/04/06 2. YA22 17(2), 22 20/05/06 3. YA33 18(1)(a) 20/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The manager should clarify the reviewing system so that all parts of each individual support plan are clearly DS0000008672.V289582.R01.S.doc Version 5.1 Page 23 Elms Park Care Home 2. YA42 reviewed. Make a call alarm system available to all service users. Elms Park Care Home DS0000008672.V289582.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Nottingham Area Office Edgeley 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. 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