Inspection on 31/10/05 for Elmside

This inspection was carried out on 31st October 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 12/04/05

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 Inspection 31st October 2005 10:30 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 Elmside DS0000019334.V266899.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. Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elmside Address Elmside Walk Hitchin Hertfordshire SG5 1HB 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) 01462 451737 01462 454298 Methodist Homes for the Aged Mrs Lynn Carter Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate four additional older people over the age of 65 years for the purpose of respite care. The manager must inform the CSCI when the rooms have been closed and building work on the extension has commenced. 12th April 2005 Date of last inspection 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 homes 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 DS0000019334.V266899.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 31st October 2005 and was conducted by the home’s leading inspection officer. All of the standards assessed were met and staff and service users gave positive feedback regarding employment conditions, management of service, care provision and the way in which the home is run generally. The inspector met with staff and service users and gained their view. Those that wanted to took part in seasonal celebrations and those that chose not to were entertained alternatively by the home’s activities co-ordinator in one of the alternative lounges. A sample of care plans and risk assessments were examined. The complaints folder, accident/incident files, a sample of staff files, fire safety record, medication storage and recording files were also examined. The activities were varied and the staff-training planner and training evidence showed commitment to providing a skilled and competent staff team. What the service does well: A comprehensive assessment is carried out for any prospective service user. Clear information is given about the home being considered with viewing encouraged before making a choice. All service users care plans and risk assessments are kept reviewed. The assessment forms part of the initial care plan and regular reviews are held. Service users and their families/representatives (where appropriate) are central to care planning. The organisation carries out its own audits and puts an action plan into place should deficits be found on sampling. The activities are very satisfactory and every month a theme day is planned e.g. during Christmas month there are several Christian activities in place (alternative activities are provided but the majority of the service users are practicing Christians and choose the home because it has a Christian provider and Christian principles). Menus reflect the season, on Burn’s day there is poetry and a menu is written up to show ‘tatees and neeps with haggis’, there is always an alternative menu, but the whole day is a celebration of the poet. Service users views are obtained and acted upon. Robust recruitment and satisfactory staff training is in place. Elmside DS0000019334.V266899.R01.S.doc Version 5.0 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 DS0000019334.V266899.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 Elmside DS0000019334.V266899.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): 3 and 4. Standard 6 is not applicable to this home. Full assessments are carried out prior to any offer of placement and so that assurances can be given that the known/assessed needs of the person can be met. 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. It is also sent out to prospective Service Users. The Commission for Social Care Inspection had been given copies of these on 12th May 2005. Comprehensive assessments are carried our prior to the offer of a placement at the home. The home does not admit service users for whom needs cannot be met. Samples of assessments were seen alongside the care plans for the same sample; these were found to be satisfactory, regularly reviewed and any assessed changes result in change to the care plan with guidance for staff. The service users involvement in the assessments, care plan and reviews, is evidenced by their signature on the care plan. Some of the service users discussed with the inspector their care plan and were well informed about information held about them. Elmside DS0000019334.V266899.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): Standards 7 - 11 The 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 with policies and proceduresto support staff and service users. Service users’ privacy is maintained and rights are protected. Care, sensitivity and respect is an assurance to service users and their families at the time of illness and death. EVIDENCE: A sample of care plans were examined by the inspector indicated that health, personal and social care needs were met. There is clear information and guidance for staff to meet the identified needs. Progress notes and review notes were up to date and provided information that needs were being met. Five of the service users gave good feedback about life at the home and also verified that they felt their needs were well met. Four other service user Service users informed the inspector that their care was provided in a dignified and respectful way. Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 10 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 Policies and procedures were in place in respect of maintaining dignity and respect for individuals, these had been reviewed. Confidentiality training is part of the induction process for all new staff and confidentiality is protected by the policies and procedures that are in place. All personal records were observed to be securely stored at this inspection. There are many compliments at the home evidencing the care and support service users were given as life drew to a close and of the support the families and friends were given at the time of death of their relative/friend. Elmside DS0000019334.V266899.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): Standards 12 - 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 is fully explained. Service users who decide that this is the right home for them are informed prior to admission of what they can expect. Service users are encouraged to maintain their social, cultural, religious and recreational interests. The inspector met with several of the service users, who stated that the home met their expectations and preferences and that they were very happy with the provision of care and activities. The visitors book shows that relatives/friends call at all times of the day/evening (including staying over where a relative or friend is ill or dying). Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 12 Service users stated to the inspector that their families and friends are always welcomed and made to feel comfortable. Representatives from the local church are frequent visitors to the home and support the meeting of spiritual expression and friendship. Residents meetings are held and the minutes of these were available for inspection. The organisation carries out its own audits 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; some of service users said the registered manager pops in to consult with them and to ensure they are happy with their service. The menu seen on the day of inspection had ‘theme day recipes’ (with alternatives for those who did not wish to join in the days fun). The menus seen at this inspection provided for a nutritious and varied diet and they were clearly displayed. The chef meets with service users to discuss the menu periodically and also on request individually. One service user informed the inspector that arrangements are made when the need arises for a meal to be served later as long as this is made known to kitchen staff. Alternative meals are provided if a service user decides they don’t want the meal they have chosen. Large windows pleasantly light the dining room. 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. Many of the service users prefer to dine with a group of service users with whom they identify best. Elmside DS0000019334.V266899.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 Complaints are dealt with in a satisfactory manner. Service users legal rights are protected and they are protected from all forms of abuse by appropraite policies, procedures and staff training. EVIDENCE: The records for complaints were produced at this inspection, the inspector examined the last three complaints recorded and was satisfied that these had been handled appropriately in line with the home’s policies and procedures, with satisfactory outcome for the complainants. Most of the service users have chosen their power of attorneys prior to coming into the home and the families are close knit and supportive and their have been no problems arising from these arrangements. The registered manager stated that if a service user did not have this support, or if the support was found not to be appropriate, advocacy services would be sought with the service user’s consent. At an earlier inspection, a service user group informed the inspector that everyone is supported to their right to vote; some service users vote via the postal system; staff stated that views regarding this are sought prior to elections and support is given at the appropriate time. Abuse awareness is maintained on the training planner (evidenced at this inspection). Early in the induction of new staff the abuse awareness training is provided and staff sign to evidence that they have read and understood the abuse awareness policy and procedure. Protection of Vulnerable Adults checks are applied for as part of the enhanced Criminal Records Bureau checks and the staff files seen for the latest recruits contained all of the information Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 14 necessary to evidence that the home had carried out its duties in recruiting staff in a robust and safe manner to protect service users. Elmside DS0000019334.V266899.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 This home is well maintained and provides for a safe environment. The home is clean, pleasant, comfortable and hygienic. EVIDENCE: Accidents and incidents records, medication records, fire safety records, COSHH and the servicing of specialist equipment records were sampled as part of this inspection. These were found to be well maintained and clearly recorded, there were no issues arising and provided evidence that service users and staff are offered the protection of reasonable safety measures. The home and gardens were seen to be well maintained. There is a rolling programme for maintenance and a quick response to any problem arising; the maintenance record and record of action taken was made available to the inspector. Health and Safety Policies and procedures are kept under review and staff training is provided as a part of a rolling programme, as is all mandatory training. The training planner was seen at this inspection and a sample of staff records examined contained copies of the certified health and Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 16 safety, infection control, food hygiene, moving and handling and fire safety training they had attended. In touring around the home, the inspector saw that the home was clean and fresh and that infection control policies and procedures were being implemented. The laundry and ancillary staff have certificates for training in infection control and the laundering of clothing is well provided for in a wellfurnished laundry; the washing machines provide for the disinfection of laundry. Standards 20, 21 and 23 were reported as having good outcomes at the last inspection in April 2005. Elmside DS0000019334.V266899.R01.S.doc Version 5.0 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 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 - 30 There is a good skill mix amongst the staff team and staffing numbers are just adequate to meet the current service users needs. Staff are provided with a satisfactory level of training to safeguard service users. Recruitment is robust to provide for the protection and support of the service users. EVIDENCE: The rota showed that staffing numbers appeared adequate. Some of the care staff stated that they were kept very busy at peak times due to the changing needs of the service users. In discussion with the registered manager, she stated that she does keep this under review and as notified under Regulation 37, arrangements are in process to transfer one service user whose needs have become more difficult to meet to another home. This has been handled sensitively as evidenced in the care plan and progress notes. The staff training records sampled at this inspection provided evidence that there is a good skill mix (see the previous sections of this report). There were records to show that formal supervision is provided on a regular basis and staff stated that their supervision is regular and supportive. The last staff meeting was held on the 4th October 2005 and the minutes showed that the meeting was well attended by staff. The home has robust policies and procedures regarding staff recruitment and these are implemented as evidenced by the staff files examined (see earlier evidence provided in this report). Staff files have all required documents in Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 18 place, which provides evidence that the adult protection policies and procedures have been adhered to. Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 19 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): Standards 31, 33, 35 and 38. A fit and competent registered manager runs the home in the best interest of the service users. The formal supervision of all staff is in place. The health, safety and welfare of service users and staff is 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 to ensure her fitness for the post of registered manager. The registered manager has consistently ensured the meeting of the National Minimum Standards. The registered manager has completed her postgraduate diploma in management and is scheduled to complete her Registered Manager Award by the end of this year; she has also commenced a one-year course to gain a diploma in Dementia Care. The registered manager stated that she has Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 20 obtained an accredited training pack (recommended by Methodist Homes) to provide Dementia Care Training for the care staff. Service users meetings are held regularly, the chairperson is elected by the service users nomination; the outcomes of the service users’ meetings are brought to the attention of the registered manager for any required action. The minutes were available for inspection. Service users views are gathered as part of the in-house/organisation audit and outcomes are recorded along with any action taken; this evidences how service users are empowered to direct positive change in the home. Currently part of the grounds are cordoned off for the protection of service users health and safety during the programme of the building of the homes extension; some of the service users did not like the view so the registered manager requested the builders to turn some of the partitions around so that they could be decorated more attractively and provide a better outlook for the service users. During this inspection relatives came to the office to say that their mother was still not happy looking out on to the builders partition and they were informed that fast growing annuals would be planted as soon as possible to improve the view but in the meantime ideas for decorating the partitions were being discussed. The relatives seemed to be happy that something would be done to improve the view whilst the partitions were required to be in place. Health and Safety policies and procedures are reviewed and training records sampled at this inspection show that new staff receive a good induction with an ongoing training programme in place. There is a Adult Protection policy and procedure and staff training/induction is required as part of these. Service users and staff spoken with confirmed that they were aware that there were policies and procedures in place for their protection. Service users stated that they would feel quite secure to lodge a complaint if necessary. Staff said that they felt that they would be supported to take a grievance if the need arose, issues are discussed during supervision and support is given if any difficulty is experienced. Staff stated that supervision time is valuable and supportive. Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 21 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation 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. Refer to Standard Good Practice Recommendations Elmside DS0000019334.V266899.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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