Inspection on 15/09/05 for Elms, The

This inspection was carried out on 15th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elms, The 12/01/09

Elms, The 15/01/08

Elms, The 27/03/07

Elms, The 28/02/06

Elms, The 15/03/05

Elms, The 17/11/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Elms, The 147, Barry Road London SE22 0JR Lead Inspector Ms Alison Pritchard Unannounced Inspection 15th September 2005 11:00 X10015.doc Version 1.40 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, The DS0000007086.V253209.R01.S.doc Version 5.0 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 Older People. 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, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elms, The Address 147, Barry Road London SE22 0JR 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) 0208 693 4622 0208 693 9403 South East London Baptist Homes Susan Baterip Care Home 25 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2005 Brief Description of the Service: The Elms is located in a residential road in East Dulwich close to local amenities such as a library, shops and several bus routes. The home is registered to provide care for up to 25 older people, at the time of the Inspection there were 22 residents who all have single bedrooms. The home has a large well maintained garden to the rear and off street parking is available. The home has been managed by South East London Baptist Homes since 1953 when the home opened. The work of the home is based on Christian principles and it is stated in the home’s Statement of Purpose that Christians from any denomination may apply. The aim of the home is stated as: ‘to provide a secure, comfortable and caring home for residents, so they can spend the rest of their days in peace and security. We provide comfort and support in a Christian atmosphere where mutual help and friendship are encouraged.’ Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over five and a half hours on a mid September day. The inspector had the opportunity to talk to seven residents, to interview two members of staff who had been recruited since the last inspection, to have a partial tour of the premises, discuss issues with the registered manager and to examine a range of records. Feedback was also received from two health care professionals. In October 2005 a visit was made to the home on an announced basis to look at recruitment records and records of residents’ finances. The findings of that visit are also reported here. What the service does well: What has improved since the last inspection? What they could do better: The main area for the home to address is for them to take up enhanced Criminal Records Bureau checks for staff who were already in post when the system was introduced. Although police checks were in place the home should have taken up checks under the new system. This matter was found on the inspector’s visit to the home in October 2005 and was confirmed to the registered manager in writing so that the matter could be addressed without delay. The home has taken action promptly to address this matter. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 6 Although care plans are in place there is scope for them to be developed further. The need for this is recognised by the managers of the home and they are being careful to ensure that a suitable new system is introduced. Care should be taken to make sure that only staff who have received appropriate training assist residents with transferring from a wheel chair to another seat. 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, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 The admission arrangements are good as they allow potential residents to have enough information about The Elms to decide whether it will be a suitable place for them to live. The home ensures that they have sufficient information to make a decision about whether they can meet the potential residents’ needs. EVIDENCE: The Elms has a statement of purpose and a residents’ guide which describe the ethos and facilities of the home. The documents includes the information required to allow potential residents to take into account when thinking about whether the home might be suitable for them. The home’s policy is for visits to be made to the home by the prospective service user wherever this is possible. The first month of a service user’s stay is regarded as a trial period. While most placements are made on a planned basis emergency admissions can be accepted if there is agreement from a placing social worker about the suitability of the placement. A suitable contract / statement of terms and conditions is issued to all residents when they come to live at the home. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 9 The files of newly admitted residents showed that the home obtains assessments from social workers. In addition senior staff from the home visit the potential resident to assess their needs. This ensures that the home has a range of information available to ensure that they can meet the potential resident’s needs. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The staff have a good understanding of the residents’ support needs although the care planning documentation needs to be developed. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. Overall medication is well managed in the home. The residents benefit from positive and respectful relationships with the staff. EVIDENCE: Each of the residents has a care plan which describes their needs and how the home will meet them. The registered manager stated that she intends to develop the care plans and this should improve the level of detail documented about the residents’ care needs. A risk assessment on one file seen about moving and handling tasks included some inconsistencies which may have led to confusion about the person’s needs, although another one viewed was in good order. The feedback from two health care professionals was good with both expressing their satisfaction with the overall care provided to residents in the home. Details of residents’ attendance at health care appointments was well Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 11 documented. This showed that the home has contact with a range of professionals to the benefit of residents. Medication is safely stored and overall is well managed. Two issues found to need attention were to ensure that the GP is asked to take care that medication administration records do not include instructions on dosage which are written using Latin abbreviations (for example qds and bds). It is recommended that the home obtain information leaflets about the medication which is prescribed for residents. Residents confirmed that staff treat them with respect, using the names they prefer, and showing consideration when they wish to be alone. Issues of privacy and dignity are the subject of discussion at placement reviews. A pay telephone is available and is located so that residents’ conversations will not be overheard. All of the residents seen during the inspection were well groomed with their hair tended and suitable and clean clothes on. The hairdresser was visiting the home during the inspection. Staff showed compassion for residents who have been bereaved and they have supported residents to attend funerals. Discussion with the registered manager showed that there is a clear understanding in the home of the importance of appropriate care for residents at the time of their death. There is also understanding of the needs of relatives at this time. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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, 14, 15 The residents benefit from a range of activities available in the home, including people visiting to provide activity sessions. The feedback from residents about the food was good, the catering staff make efforts to meet individual needs and preferences. EVIDENCE: There are a range of activities in the home, a pianist visits once a week to play for residents, other musical sessions are held and during term time children from a local school visit to talk to residents. There are a range of games available for staff to use with residents, including board games and dominoes. During the summer period an outing to Eastbourne had been arranged. Some residents are supported to join community based activities including attending social clubs. There is good attention to residents’ spiritual needs, local clergy visit, some residents go to Churches in the local area and others attend the services which are held in the home. In the month following the inspection a Thanksgiving day was to be held at a local church. Visitors are able to come to the home at all reasonable times and without prior arrangement. There are good links with community based groups. Discussion Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 13 with the manager showed an awareness of the importance of residents maintaining relationships of importance to them and the home supports residents to have contact with family and friends. Residents who are able to do so handle their own financial matters and this is encouraged by the home, otherwise relatives are encouraged to provide this support. Residents are able to bring personal possessions with them to the home so that they can personalise their rooms. Catering staff showed awareness of residents’ dietary needs and preferences. The menu is planned in advance although residents and staff confirmed that alternatives can be provided in response to individual choice. The recently amended menu showed that the main meal is served at lunch time and a smaller tea time meal is served in the evenings. The menu includes fresh fruit and vegetables. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The arrangements for dealing with complaints contribute to the protection of residents. Staff knowledge of adult protection issues provides a safe environment to protect residents. Arrangements for the safe storage of items for residents can be improved by ensuring that a member of staff signs to confirm receipt of the item. EVIDENCE: The complaints procedure is included in the service user guide issued to service users. It includes the details of the CSCI and appropriate time scales. The procedure states that: ‘We view complaints as an opportunity to identify anything that is going wrong at The Elms and to put it right. Your comments and suggestions are always welcome.’ Residents said that they knew how to raise concerns and would feel confident that they would be addressed by the home. There have been no substantiated complaints since the last inspection of the home. A new member of staff confirmed that the induction process included input on issues of abuse and the action to take if they had such concerns. Other members of the staff team have undertaken training in these issues. The policy on abuse is under review. It is recommended that a copy of the reviewed document be sent to the CSCI when the process is complete. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 15 There are safe arrangements in the home for the management of residents’ financial matters. The arrangements for the storage of residents’ valuables would be improved by ensuring that both the resident and the member of staff who receives the items signs the record. If the resident is unable to sign the record should be signed by two members of staff. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 26 The residents benefit from a comfortable, homely and clean building. Some aspects of the building do not meet the required standards. There are plans to address these problems and it is anticipated that this will greatly improve the facilities available. EVIDENCE: Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 17 The home is suitably located in a residential street in East Dulwich close to public transport routes and local facilities such as a library, Churches, and shops. There is a large, well maintained and safe garden to the rear of the home. There is an accessible entrance at the side of the home. Within the home residents who are wheel chair users can access part of the first floor via a passenger lift. The home is an older building which lends a very homely feel but South East London Baptist Homes acknowledge that there are a number of problems relating to the layout of the home and there are plans drawn up to address these. The managing organisation is committed to ensuring that the building is improved to the benefit of residents. It was noted during a partial tour of the building that a shower room has a large bolt on the outside of the door. This was both unsightly and risky and was pointed out to the registered manager as it needed to be removed, she agreed to make arrangements for this. It has been confirmed that the bolt was removed later on the day of the inspection. The communal areas consist of four lounges (one large and three smaller rooms) and a dining room. This allows residents to have a choice of where to sit. Redecoration in one of the lounge areas has been carried out over the summer period. Residents were involved in choosing the colours used. There is a well kept and attractive garden to the rear of the home. Sun shades are available and the garden is well used during the warmer months. The home was very clean and hygienic at the time of the inspection and there were no offensive odours. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Staff morale is high, the staff demonstrate commitment to the residents and meeting their needs. There are enough well trained staff who know the residents well to meet their needs. New staff are helped to learn about the residents’ needs and how the home runs. Recruitment records did not include all of the required information. Required checks had not been taken up on longer standing members of staff, but the necessary checks have now been applied for and many have been returned. EVIDENCE: The staffing levels are for there to be one senior member of staff and four care staff on duty in the morning and one senior and three care staff in the afternoon and evening. Overnight there are two waking night staff on duty with access to an on call senior member of staff who is on the premises. This is suitable for the needs and number of residents. The home has exceeded the required standard in relation to NVQ training. The majority of care staff have already achieved NVQ level 2, some staff, including the deputy manager and another member of the senior team have achieved NVQ level 3. Other staff have begun training towards the qualification. Staff recruitment files for new and longer standing staff were examined. It was found that the appropriate checks of longer standing members of staff by the Criminal Records Bureau had not been taken up, although the previously required police checks were in place. This was discussed with the manager on Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 19 the day of the visit and confirmed in writing two days later. The home has now applied for the necessary checks and many have been returned. For the more recently recruited members of staff some of the checks and documents specified by Regulation (schedule 2 of the Care Homes Regulations 2001) were not on file, although each of the people had enhanced checks taken up by the Criminal Records Bureau as required. The Registered Person should consider the introduction of a checklist system for recruitment files. All staff receive a minimum of three paid training days a year. New members of staff undertake induction training which covers issues relevant to their role in the home. The feedback from newer members of staff was that they were supported to join the staff team and given an appropriate level of supervision and advice. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 36, 38 The residents benefit from an experienced and qualified manager who is committed to providing good quality care in the home. Staff are well managed and supervised and there are clear communication systems in the home. one matter to be addressed is for only trained staff to assist with moving and handling tasks, other aspects of health and safety were managed well. EVIDENCE: The manager of the home has been registered since September 2004. She is appropriately qualified and experienced for the role and the feedback that the inspector received, from both residents and staff, about her work was very positive. Staff have the opportunity to raise issues with the registered manager through informal contact on a day to day basis and through formal meetings. There are regular whole team staff meetings, senior staff meetings and meetings with the kitchen staff. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 21 Wherever possible residents’ finances are managed by the resident themselves or their relatives. The manager is not appointee for any of the residents. Some small amounts of money are held by the home on residents’ behalf and some items such as newspapers and hairdressing costs are dealt with on residents’ behalf. Records of these transactions were in good order. Staff confirmed that they receive supervision and that this has been arranged to take place six times a year as required. Overall health and safety matters are well managed in the home. staff have received training in health and safety matters, moving and handling issues and are undertaking refresher training in food hygiene. Requirements made by food hygiene authorities in July 2005 have been met. Arrangements for fire safety in the home were found to be met at the last inspection in March 2005. One observation made during the inspection was that a visiting professional assisted a resident into a wheelchair and this may have put the resident at some risk. The matter was relayed to the registered manager who agreed to address the matter and ensure that only trained staff from The Elms carry out such tasks. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 x x x x x 4 STAFFING Standard No Score 27 3 28 4 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x 3 3 x 2 Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? yes 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 OP7 Regulation 15(1) Timescale for action The Registered Person must 01/07/06 ensure that the care plans are further developed to ensure that they fully address the range of residents’ needs in sufficient detail. The Registered Person must 01/12/05 ensure that the GP is asked to take care that instructions on medication administration records do not include Latin abbreviations. The Registered Person must 01/12/05 ensure that the arrangements for the storage of residents’ valuables are improved by ensuring that both the resident and the member of staff who receives the items signs the record. If the resident is unable to sign the record should be signed by two members of staff. The Registered Person must 01/12/05 confirm that Enhanced Criminal Record Bureau checks have been taken up on all members of staff. The Registered Person must 01/12/05 ensure that proof of identity, including a recent photograph DS0000007086.V253209.R01.S.doc Version 5.0 Page 24 Requirement 2 OP9 13(2) 3 OP18 17(2)sch4 4 OP29 19(1)(b) (i) 19(1) (b)(i) 5 OP29 Elms, The 6 OP38 13(4)(c) and two written references have been obtained prior to employment of a staff member. The Registered Person must 01/12/05 ensure that only trained staff assist residents with moving and handling tasks. 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 Refer to Standard OP29 OP9 Good Practice Recommendations The Registered Person should consider the introduction of a checklist system for recruitment files. It is recommended that the home obtain copies of patient information sheets about medications so that staff are aware of the side effects and interactions that are associated with the medication they are administering. Elms, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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, The DS0000007086.V253209.R01.S.doc Version 5.0 Page 26 - 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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