Inspection on 12/04/05 for Elmside

This inspection was carried out on 12th April 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 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

Elmside 16/02/09

Elmside 24/04/07

Elmside 31/10/05

Elmside 05/11/04

Elmside 09/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Elmside Elmside Walk Hitchin Hertfordshire SG5 1HB Lead Inspector Hazel Wynn Unannounced 12 April 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elmside Address Elmside Walk Hitchin Hertfordshire SG5 1HB 01462 451737 01462 454298 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Methodist Homes for the Aged Mrs Lynn Carter Care Home 38 Category(ies) of OP OP Old age registration, with number of places Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 05.11.04 Brief Description of the Service: Elmside is a care home providing personal care and accommodation for 38 older people.It is owned by Methodist homes for the Aged, which is a voluntary organisation.The home is located in a quiet cul-de-sac in the centre of Hitchin, close to town centre shops, churches, pubs, the post office and other amenities.The home was opened in 1985 and consists of a two-storey building with parking to the front and a large garden to the rear.All the home’s bedrooms are single, and three of the bedrooms have en-suite facilities. There is a passenger lift. The home has extensive gardens that are well maintained and easily accessible, and an enclosed courtyard. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 12th April 2005 and was conducted by two inspection officers. All of the standards assessed were met and staff and service users gave positive feedback regarding employment conditions, management of service, user care and the way in which the home is run generally. What the service does well: The service supports service users in choice of home; it provides a clear service user guide and encourages service users to visit the home prior to accepting a trial stay. The actively seeks users views and will make changes where possible to incorporate their views by making changes both on an individual basis and collectively. The home carries out thorough assessments of needs and does all that is reasonable in ensuring service user and staff safety and protection. The home provides a good variety of appropriate activity and service users are actively encouraged to maintain links with the community. Links with family and friends are well supported. The home is clean and comfortable and service users are encouraged to make it their home, through inclusion in decision-making and encouragement to personalise individual rooms. A good variety of nutritious food is served in a comfortable setting and service users are consulted and give input to menu planning and the chef seeks feedback from the service users regarding the quality, quantity and variety of food served. The home has a “Friends of Elmside” committee who are fully involved with the service users; they fund raise and consult with service users in endeavours to add to the provisions made to aid the quality of life at Elmside. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 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 standard(s) 1,3 and 5. Standard 6 is not applicable. The home provides prospective Service Users with information about the home encourages visits to be made prior to making a choice and carries out a full assessment of need to ensure it has the capacity to meet that need. Each Service User is give a copy of the contract signed by both parties. EVIDENCE: There is an up to date Statement of Purpose and comprehensive Service User Guide. Service Users are given a copy of the Service User Guide on admission to the home and is also sent out to prospective Service Users. The Commission for Social Care Inspection Inspector has been given copies of these. A full assessment is carried out, by a person qualified to do so; this is done in conjunction with all significant professionals and including the Service User; this ensures the home has the capacity to meet needs. Assessments are on file and form the basis of the initial Care Plan. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 9 Service users and their families are actively encouraged to visit the home before reaching a decision that it appears to be suitable for them. The pack sent out by the home, states this. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 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 standard(s) 7,8,9 and 10. Service Users health, personal and social care needs are set out in the individual care plan. Health care needs are fully met. Medication is well managed and policies and procedures are in place. Service users’ privacy is maintained and rights are protected. EVIDENCE: The care plans for named individuals health, personal and social care needs contained clear information and guidance for staff to meet the needs. Some service users had assessments that had not been signed and a recommendation was made for this to be done. Progress notes and review notes provided information that needs were being met. Service users spoken with also verified that they felt their needs were well met. Policies and procedures are in place to protect Service Users who are able to manage their own medication; this is kept reviewed and risk assessments are in place. A lockable space is provided. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 11 Policies and procedures are in place in respect of maintaining dignity and respect for individuals. Service users spoken to stated that their care was provided in a dignified and respectful way. Confidentiality is protected and policies and procedures are in place. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15. Service User’s individual lifestyles experienced in the home match their expectations and preferences. Social, cultural, religious and recreational interests are catered for wherever possible. Service users are supported to have control over their lives and to make choice. Contact with family and friends is supported; visitors are made very welcome. Wholesome and balanced diets are served in congenial settings and Service Users have a choice of menu. EVIDENCE: The statement of purpose and service user guide clearly states that this is a Methodist home and the ethos of the organisation. Service users who decide that this is the right home for them are well informed prior to admission of what they can expect. Service users are encouraged to maintain their social, cultural, religious and recreational interests. Service users spoken with stated that the home met their expectations and preferences very well indeed. Relatives are encouraged to visit the home at any time and are always made welcome; as verified by service users spoken to. Representatives from the local church are frequent visitors to the home and provide for spiritual expression and friendship. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 13 Residents meetings are held and audits carried out to support service users to voice their opinions regarding how their expectations and preferences are being met and action will be taken to remedy any dissatisfaction. The menu seen provided for a nutritious and varied diet. The dining room is pleasantly lit by large windows and one service user who has failing sight has been provided with an additional spot light to aid her. The dining room is comfortably laid out and provision is made for service users to take their meal in their own room if this is preferred. Most service users prefer to dine with a group of service users with whom they have made friends or identify with. The chef meets with service users to discuss the menu periodically and also on request individually. Staff stated that although there are set times for meals individual arrangements are made when the need arises, i.e. if a service user is going and returning late or for some other reason if this is made known. Alternative meals are provided if a service user decides they don’t want the meal they have chosen. We observed that not all of the Service Users could recall what they had chosen, although choice is made on a daily basis, we suggested that the menu of the day could be displayed and the staff stated this could easily be arranged. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 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 standard(s) 16 and 18 The home will deal with any complaint in a satisfactory manner in accordance with its policies and procedures and take appropriate action. Service users legal rights are protected and they are protected from all forms of abuse by the homes policies procedures (which includes a whistle blowing policy) and through robust recruitment and staff training. EVIDENCE: There is a clear complaints policy and procedure and a record of all complaints is kept; this shows that a timely response is made and wherever possible the complaint is resolved satisfactorily; for example, one service user, who’s sight is failing, complained that the dining room did not provide enough light for her. In addition to seating her at a table placed by the large windows the home have also provided a spotlight above where she is seated. Records pertaining to Service Use care and Health and Safety are maintained. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 15 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 standard(s) 19,20,21,23 and 26 The home follows its policies and procedures in the maintenance of a safe and well maintained environment. There are adequate communal and personal facilities for toileting and bathing/washing. Personal rooms are personalised and any specialist equipment is in place for those who require it. The home is clean and pleasant/comfortable and the gardens are well maintained. Good hygiene practices are adhered to. EVIDENCE: Health and Safety Policies and procedures are in place and records seen provided evidence that service users and staff are offered the protection of reasonable safety measures. We observed that the home and gardens were well maintained; there is a rolling programme for maintenance in addition to quick response to any problem arising. The home and gardens are accessible and provide for safe and sufficient access to suitable washing/bathing and toilet facilities. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 16 Service users own rooms are well maintained and comfortable. Service users may bring personal possessions and suitable furnishings of their own into the home in order to personalise their own space. We observed that couples are provided with two rooms and may use one room as a lounge and the other as a bedroom if they so choose. There are plans to extend the home and this will have a temporary effect on the present accommodation of four service users own rooms. The inspector looked at plans and the manager took the inspector to visit four alternative rooms that will need to be offered as temporary accommodation whilst work on the extension is in progress. A lot of though and planning has gone into creating as little disruption possible and there are plans to fully involve the four service users following the consultation and approval of the rooms by the Commission for Social Care Inspection. The rooms to be offered are above the size required by the standards and will be refurbished (as they are currently not service user accommodation but rooms used for company business). We met with the Friends of Elmside who are very involved with the service users endeavouring to ensure that quality of life is optimised. We observed that the home was clean, pleasant with no mal odours detected and that there were procedures in place to ensure good hygiene practices were carried out; for example, the laundering of clothing is well provided for in a well furnished laundry with machines capable of disinfection of laundry. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home is adequately staffed by trained staff ; there is a mix of skills within the team to meet the needs of the Service Users. The homes recruitment procedures are robust. EVIDENCE: The rota showed that staffing numbers appeared adequate. Discussions with staff and observations denoted that there was a good skill mix of staff. All staff are provided with induction and ongoing training via the rolling training programme. The manager stated that Care plan training is planned. There were records to show that formal supervision is provided on a regular basis. The home has robust Policies and procedures regarding staff recruitment and puts these into practice. Staff files have all required documents in place which provides evidence that the adult protection policies and procedures have been adhered to. The manager discussed with us the difficulties that can be experienced whilst waiting for CRB checks to be returned before new employees can commence work. The manager was advised to consult with the Commission for Socail Care Inpsection when lengthy delays, in awaiting the return of CRB checks, are causing disruption in the provision of service to the service users. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,38 The home is well run, in the best interest of the Service Users, by a competent registered manager. Service Users financial interests are safeguarded and formal supervision is in place. The health, safety and welfare of Service Users and Staff are promoted and protected. EVIDENCE: The manager has several years experience of running this home, her application for registration was approved, which means that robust checks were carried out. Service users and staff have testified to her commitment and she has consistently managed this home very well. Service users hold meetings and select their own chairperson; the outcomes are brought to the attention of the registered manager for any required action. There is strong evidence that service users are empowered to direct positive change in the home. Meetings of minutes, service users views in audits are recorded and maintained with a record of outcomes. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 19 Health and Safety policies and procedures are reviewed and training records show that all staff have received good induction to ensure that all reasonable steps are taken to ensure the protection of service users and staff is in place. There is a Adult Protection policy and procedure and staff training/induction in the procedure. Service Users and Staff spoken with confirmed to us that they were aware that there were policies and procedures in place for their protection; they were also aware that there Complaints and Grievance Policies and procedures and stated that they would feel quite secure to lodge a complaint if necessary. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 x x 3 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 Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 x x 3 Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation n/a Requirement Timescale for action 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 OP7 Good Practice Recommendations All Care plans should contain assessment of need and risk assessments that have been signed by the assessor. All care plans and their reviews should bear the signature of the service user and reviewer. Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire 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 Elmside I52 s19334 Elmside v222735 120405 stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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