Inspection on 28/02/06 for Elms, The

This inspection was carried out on 28th February 2006.

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, The 12/01/09

Elms, The 15/01/08

Elms, The 27/03/07

Elms, The 15/09/05

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 28th February 2006 10:45 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.V272004.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.V272004.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 susan@theelms.co.uk 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.V272004.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 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 21 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.V272004.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 six hours over a late morning and afternoon at the end of February 2006. The majority of core standards (which must be assessed at least once each year) had been examined at the last inspection of the home in September 2005. As a result this inspection was focussed on the home’s progress towards meeting the requirements of that inspection. The inspector had the opportunity to talk to five residents and to a visiting health care professional about their experience of The Elms. The inspector also saw the communal rooms, had discussions with the deputy manager and the secretary and examined a range of records. Everyone at the home was welcoming and helpful and the inspector is grateful for their contributions to the inspection. What the service does well: What has improved since the last inspection? The home has introduced a quality assurance system to find out the views of residents about the care provided and the home’s facilities. The process is not yet complete but those questionnaires seen indicated high levels of satisfaction amongst the resident group. The requirements of the last inspection have been addressed and there are plans to implement a new care planning system which is suitable for the needs of the residents. Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 6 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, The DS0000007086.V272004.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.V272004.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): 2, 3, 5 People who come to live at the home are helped to settle in by staff and care is taken prior to admission to ensure that their needs can be met at The Elms. EVIDENCE: The inspector had the opportunity to speak to several residents, one of whom had been recently admitted to the home. The feedback received was that staff are helpful when a new resident comes to live at the home, assisting them to unpack and providing information. A service user’s file showed that the Registered Manager had gathered information from the people who referred the person to the home, had visited the potential resident in hospital and undertaken an appropriate range of assessments to ensure that the home was a suitable placement. Although the person was unable to visit the home immediately prior to their admission they were familiar with the home from a previous visit and this assisted with settling in. A copy of a written contract between the home and the newest resident was seen on the person’s file, it included the information required. Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 9 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): 8, 9, Residents’ healthcare needs are met and medication is managed well. Medication administration records must include details of allergies. EVIDENCE: On admission a new resident is referred to a range of health care professionals for assessment and the home ensures that any recommendations that they make are followed up. Feedback was received during the inspection from a visiting health care worker. The information was that the home provides good care which is in accordance with their recommendations, that records are well kept and that concerns are passed on appropriately. Medication is stored properly and safely. The medication records of administration were in good order with no unexplained gaps. Information about residents’ medication had been provided by the pharmacist with whom the home has a good working relationship. The only matter which needed attention was that some of the medication administration records did not have entries to record residents allergies. This was pointed out to a senior member of staff who agreed to ensure that this was amended. Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 10 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, Residents’ social, cultural, recreational and religious needs are well met. EVIDENCE: The home operates according to a Christian ethos and there is understanding of residents’ religious needs. Each morning there is a time for reflection and religious services are held each Wednesday and Sunday in the home. Arrangements are made to support residents to attend churches in the local area if this is their preference. The inspection took place on Shrove Tuesday and the menu included pancakes to mark the day. During the week after the inspection one of the residents was to have her 100th birthday. Celebrations were planned for the day. Activities in the home are mostly organised by the staff team and include a range of games, a piano player visits occasionally and musical sessions are held. A mobile library visits the home each month so that books can be borrowed and these are available in large print. Newspapers are delivered to the home at residents’ request. A hairdresser visits the home each week. There are good links with the local community, with residents being assisted to be members of social clubs and use local facilities, particularly in warmer weather when more trips out are organised. Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 11 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 Staff and managers of the home take complaints seriously and aim to ensure residents’ views are listened to. Staff training in adult abuse matters ensures that they are alert to concerns about residents’ safety and know what action to take in such an event. EVIDENCE: Residents asked were aware of how they could raise a concern if need be and were confident that staff and managers of the home would do what they could to solve any problems. There have been no complaints made since the last inspection. The complaints procedure was found at the last inspection to meet the standard required. Staff were to undertake further training in adult abuse issues in the month after the inspection. The induction of new staff to the home includes input on such matters. The secretary agreed amendments to be made to the procedures for the storage of valuables and this improves the security of the system. Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 12 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, 23, 26 The building is very clean, hygienic and provides residents with an attractive and homely place to live. EVIDENCE: 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 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 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. The communal rooms are comfortable and homely. 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 suitably tidy at the time of the inspection. There were no offensive odours. Residents and their relatives are encouraged to Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 13 personalise their bedrooms and there are many personal touches in the communal areas, such as photographs and residents’ art work on display. There are well developed plans to undertake work in the building with the aim of increasing some room sizes and modernising some areas of the building. Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 14 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, 29 There are enough staff who are experienced and familiar with residents’ needs to provide good quality care. New staff are recruited safely and the required checks are made to ensure they are suitable. EVIDENCE: On the day of the inspection there were five staff members on duty on the morning and four in the afternoon. Each shift includes a senior member of staff. Overnight there were two people on waking night duty and one senior member of staff sleeping in the building and on call. This staffing level is suitable for the numbers and needs of the residents. Additional staff carry out catering, cleaning and laundry duties. Many of the staff have worked at the home for a long period and are very experienced in caring for older people. They are also familiar with the policies and procedures of The Elms and the needs of the residents. Action has been taken since the last inspection to improve the staff recruitment procedures. Records viewed showed that all staff have the appropriate range of checks and references in place to ensure that they are suitable to work with older people. Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 15 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): 33, 38 The systems for resident consultation in this home are good with a variety of evidence that indicates that residents’ views are both sought and acted upon. Most aspects of health and safety in the home are managed well, but staff must be sure to always use foot plates on wheelchairs so that residents are safe. EVIDENCE: A quality assurance system has been introduced since the last inspection. This complements the informal consultation with residents and their relatives. The aim of the new system is to formally seek the views of residents about the care provided and the facilities of the home. The process is not yet complete but those questionnaires seen indicated high levels of satisfaction amongst the resident group. Many letters from relatives were seen and they also were positive about the home and the care provided. Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 16 Although members of the management committee regularly visit the home copies of the reports of the visits have not been sent to the CSCI as required. The one matter relating to safety in the home at the last inspection has now been addressed. Staff were due to undertake further training in moving and manual handling, had received training in food hygiene and the recommendations of food hygiene authorities have been met. One issue needing attention, was reported back to the deputy manager during the inspection. This concerned the need to ensure that staff use footplates fitted to wheelchairs when they are assisting residents as one instance was observed of a resident being assisted in a wheel-chair without the use of the footplates. Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 17 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 x 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x 3 x x 4 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x x x 2 Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 18 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 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. This was within timescale at the time of the inspection and so was not examined. The Registered Person must 01/05/06 ensure that medication administration records include details of residents’ allergies. The Registered Person must 01/05/06 ensure that copies of the reports of the management committee visits to the home are sent to the CSCI. The Registered Person must 01/05/06 ensure that staff use foot-plates on wheel-chairs correctly so that residents are not placed at any risk. Requirement 2 OP9 13(2) 3 OP33 26(5)(a) 4 OP38 13(5) Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elms, The DS0000007086.V272004.R01.S.doc Version 5.0 Page 20 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.V272004.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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