CARE HOMES FOR OLDER PEOPLE
Elmsdene Care Home 37-41 Dean Street South Shore Blackpool Lancashire FY4 1BP Lead Inspector
Mrs Ruth Edgington Unannounced Inspection 12th December 2005 09:00 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 Elmsdene Care Home DS0000065303.V269418.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. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Elmsdene Care Home Address 37-41 Dean Street South Shore Blackpool Lancashire FY4 1BP 01253 349617 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) Sheridan Care Limited Mrs Hazel Linley Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service is registered to accommodate a maximum of 33 service users in the category OP (older persons 65 and over) The work required by the pre-registration agreement will be met within the stated timescales. Date of last inspection Brief Description of the Service: Elmsdene is an adapted property, situated in an area of Blackpool, which is predominantly holiday accommodation. The availability of local shops and facilities could be seen as an advantage for those able to continue to maintain links with the community. The home is registered to accommodate a maximum of thirty-three persons over the age of 65 years. The accommodation consists of twenty-five single bedrooms, nine of which have en-suite facilities and four double bedrooms, two of which have en-suite facilities. There is a passenger lift, which enables easy access between the ground and first floor. A variety of aids are provided around the home to meet the needs of the residents. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that commenced at 9.30 am and took place over 3hours. The Inspector spoke to the homeowner, deputy manager/training co-ordinator, four members of staff and numerous residents during the inspection. Conversation with residents was very much dependent on their ability or wish to speak to the Inspector. The Inspector was unable to speak to the registered manager as they were on sick leave at the time of the inspection. A sample of staff and residents’ records were seen and a tour of the home was carried out. In the past eleven weeks the home has been taken over by the new owners. The Inspector took into consideration when carrying out this inspection and writing the report, the short period of time that they have had to influence changes. What the service does well: What has improved since the last inspection? Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 6 Examination of staff records confirmed that the home’s recruitment procedures were now being followed consistently, ensuring that all staff were fully vetted before they commenced work so that residents were not place at risk. There had also been in increase in the number of staff employed in the home and a re organisation of roles to make staff more efficient and improve the care provided to residents. The Inspector found that in the short period of time that the homeowner had been in the home they had identified many improvements that they wanted to make. Many of the changes involving staff and care practices are to commence on the 2nd January 2006. Staff confirmed that they were looking forward to the changes. The new owner has upgraded the laundry and kitchen and provided a new toilet on the ground floor, which is suitable for use by residents who require assistance. On taking over the home the new owner was required to undertake work that was agreed in a pre-registration agreement, which was to be carried out within a stated timescale. The Inspector was pleased to find that the majority of work was completed and assurance was given the small amount of remaining work would be done within the timescale. 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
Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 8 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 Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 9 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): These standards were not assessed. EVIDENCE: Elmsdene Care Home DS0000065303.V269418.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): These standards were not assessed. EVIDENCE: Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 11 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 & 14 The social, cultural, religious and recreational interest of residents are well managed. Residents are encouraged to have control and choice over their lives within their capabilities. EVIDENCE: The Inspector examined the records of three residents and found that they contained sufficient information to enable the staff to meet the needs of each individual resident. The Inspector was shown a copy of a residents’ entertainment questionnaire that is to be used, which will enable the staff to update and change activities that are organised and ensure that these continue to meet individual and group needs. The homeowner told the Inspector that two residents go out to church and the local vicar visits on a monthly basis. The Inspector was also able to evidence that the staff had acknowledged a resident’s wish not to participate in Christmas activities because of their religious belief. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 12 During the Inspection music was playing, which the resident found to be more familiar to them and several residents were singing along. The abilities of the residents to make their own decisions varied greatly throughout the home. However from observations and comments made by residents and staff the Inspector was able to evidence that they were able to make their own decisions within their capabilities. A tour of the home confirmed that residents had been encouraged to bring their own personal possessions with them on admission to the home. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 13 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 in place for handling complaints ensure that people feel confident that their complaints will be listened to and taken seriously. Procedures for dealing with and reporting abuse procedure were satisfactory ensuring that people are adequately protected. EVIDENCE: The home has a detailed complaint procedure, which is made available to all residents on admission to the home. Comments received from residents confirmed that they knew who to complain to if they had any concerns. Staff spoken to confirmed that they felt confident that any concerns that they had would be taken seriously and acted upon by the homeowner. The Inspector was shown a new system that had been developed for the recording of any complaints, which would ensure that full information is recorded on the complaint, the action taken and the outcome. The home has a procedure in place for dealing with allegations of abuse. The management and staff spoken to had a good understanding of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 14 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 & 25 A programme of upgrading and refurbishment is in place to ensure that residents live in a comfortable, homely and safe environment. EVIDENCE: During the inspection, the Inspector discussed with the homeowner the matters that were outstanding from the previous inspection or that had been placed as a condition of registration on the Registration Certificate, which was issued in September 2005. There were still two radiators in bedrooms that had not been fitted with covers. However these rooms were not occupied and before any resident would be admitted to those rooms, the homeowner confirmed that covers would be fitted. The Inspector was shown a copy of the electrical wiring certificate that had been required as part of the pre-registration agreement. This was satisfactory and indicated that a re-test would be required in five years time.
Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 15 Work on the fire escape had been completed and the fire brigade were to be asked to revisit to confirm that it now met their requirements. Work to the passenger lift should be completed within the timescale set. During the inspection the Inspector was shown improvements that had been made in the very short period of time that the new owners had been in the home. The home was warm, clean and free from any offensive odours. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 16 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): 29 The policies and procedures for the recruitment of staff are robust and provide safeguards for the protection of residents. EVIDENCE: The home has reviewed its recruitment procedures since the last inspection to ensure that all the documentation required by regulation is in place before new staff members commence working in the home. Appropriate checks had been undertaken for the staff recruited since the homeowner took over. The Inspector spoke to two of these staff and found that they were able to confirm that they had gone through a formal recruitment and induction process. Both said that they had settled in very well and felt supported and able to go to the management if they had any concerns. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 17 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 & 35 The home is well managed and run in the best interest of the residents. EVIDENCE: The homeowner is a Registered General Nurse and Registered Sick Children’s Nurse and has a range of experience in caring for the elderly, both in nursing and residential establishments. She also intendes to undertake training to obtain a Diploma in Management. At the time of the inspection the registered manager was on sick leave. The manager also has many years experience in a management position caring for the elderly and has obtained the Registered Managers Award and was to undertake level 4 NVQ (National Vocational Training) in care. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 18 The Inspector spoke to staff that had been in the home for a number of years and received very positive comments about the recent changes in ownership and the effect that this had on the residents and staff. One member of staff said that they felt changes that had been made were for the better and that they had enjoyed the changes. They said that the felt that the homeowner was very approachable and open to suggestions. The Inspector was also able to witness the warm friendly approach that there was between management, staff and residents. The Inspector spoke to the administration officer who is responsible for recording residents’ finances. Records for money being handled by the home on behalf of the residents were examined and found to be up to date and correct. Receipts were kept of all expenditures and moneys were securely locked away. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 19 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 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x 2 x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 x x x Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 20 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 OP25 Regulation 13 Requirement All radiators must be guarded or have low surface temperature. Timescale for action 31/03/06 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 OP31 Good Practice Recommendations The registered manager should ensure that they gain a level 4 NVQ in care. Elmsdene Care Home DS0000065303.V269418.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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