This inspection was carried out on 11th June 2010.
CQC found this care home to be providing an Good service.
The inspector found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for older people
Name: Address: Elmsleigh Care Home Elmsleigh St Andrews Road Par St Austell Cornwall PL24 2LX two star good service 12/05/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Gail Richardson Date: 1 1 0 6 2 0 1 0 Information about the care home
Name of care home: Address: Elmsleigh Care Home Elmsleigh St Andrews Road Par St Austell Cornwall PL24 2LX 01726812277 01726815479 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Susan Windsor Type of registration: Number of places registered: Conditions of registration: Category(ies) : Robert Gregory Thomas care home 48 Number of places (if applicable): Under 65 Over 65 0 0 dementia mental disorder, excluding learning disability or dementia Conditions of registration: 48 48 The maximum number of service users who can be accommodated are 48. The registered person may provide the following category of service only: Care home providing nursing or personal care - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia, excluding learning disability or mental disorder (Code DE) maximum 48 places Mental disorder, excluding learning disability or dementia (Code MD) maximum 48 places Date of last inspection
Care Homes for Older People 0 6 1 1 2 0 0 9 Page 2 of 9 Brief description of the care home Elmsleigh provides nursing care for service users who have a dementia and or a mental disorder. Elmsleigh is a period property in a peaceful area, set in extensive secluded attractive grounds approached by a long drive. Car parking is available. The home is situated in Par, approximately three miles form the town of St Austell. Residents private accommodation is set out across two floors in the main house where there is a stair lift to provide access to the first floor accommodation. Some of the bedrooms are only accessible to residents with good levels of mobility due to relatively steep stairs. All of the bedrooms are for single occupancy and there are sufficient bathing facilities. The new extension known as the bungalow is on one level and all single bedrooms are provided with en suite bathroom facilities. The communal facilities include two dining rooms, a variety of lounge areas and in the bungalow residents and their relatives have access to a communal kitchen. The home is run and managed by the registered provider and registered manager with a team of staff to assist them. The fees range from £357.00 to £775.00 per week. Toiletries, newspapers and certain activities are the financial responsibility of the resident. Care Homes for Older People Page 3 of 9 What we found:
This was an unannounced inspection, which took place over two hours on the 11th June 2010 by Compliance Inspector Gail Richardson. The random inspection is part of a review as a result of concerns raised about staffing levels and management of peoples supervision of care. The purpose of the inspection was to ensure that peoples needs are properly met, in accordance with good care practices and the laws regulating care homes. For the purpose of this inspection the term We will be used when referring to the Care Quality Commission. We looked at staffing rotas and documents relating to the management of staff and took a short tour of the home.The deputy manager was on the premises and spent time assisting us. What the care home does well: What they could do better:
We found that the management of the service has been undertaken by two staff sharing the role. We identified that there was no designated and agreed clinical lead role. This is needed to ensure that all areas of clinical practice are coordinated and managed by one person who is responsible and auditable for that purpose. As stated above the registered provider has, since the inspection, told us that he has addresed this area and we will review this management arrangment. Following the inspection we were advised by the registered provider that the role of nursing Clinical Lead had been filled. A further post of lead Registered Mental Nurse lead had been allocated to ensure that areas around management of this specialist provision were also managed and auditable. We are advised that post of these roles are temporary. We required that each of the roles have in place a clear and detailed job description to ensure that staff are aware of their roles within the service. This will also ensure that other staff have a clear line of reference should they have any questions. We are advised that as part of this role on call arrangements have been agreed. We identified that recruitment of staff is underway to address shortfalls and stabilse the staffing levels of the home. The deputy manager demonstrated a clear understanding of the recruitment process. We recommend that all staff who commence employment
Care Homes for Older People Page 4 of 9 having received an POVA First check (Protection of Vulnerable Adults ) but prior to a CRB (Criminal Record Bureau Check) having been received, have a clear record of their supervised practice.We recommend that this record is maintained as a clear audit trail of the homes supervision of staff until all the recruitment checks have been received at the home. We asked how the levels of staffing had been identified,it was unclear how the calculation of staff to resident ratio had been calculated. The home must ensure that each person has a regular review of their level of dependency and this review informs the level of staffing at the home. This means that if people need more care it is identified and staffing levels adjusted accordingly to ensure that peoples care needs are met. We noted that whilst staffing levels had been consistent for the week prior to the inspection, on the day of inspection there were three care staff missing due to ill health. The staffing agency used by the home had not been able to supply any staff. The registered person is recommended to review the practice of only having one agency available. We discussed with the deputy manager how staff training is being managed. The deputy manager is currently undertaking a staff training matrix to identify any shortfalls in staff training. A copy of this is to be forwarded to the Commission for our records. The deputy manager has identified some gaps in staff training and is in the process of planning two paid staff training days for all staff to ensure that all areas of mandatory training have been completed. This is required to ensure the safety and protection of people using the service. We observed that some areas of the home, with particular reference to some external aspects of the building appear unclean and in need of some maintenance to ensure that they provide a clean, safe and pleasant environment for people using the service. All areas of the home must be clean and safe for people using the service. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 9 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 24 16 The registered manager of 16/12/2009 the home must ensure that all areas of the home have suitable fixtures and fittings which are in good repair and that all areas have a satisfactory standard of hygiene. This is needed to ensure that all areas of the home are clean, well maintained and there is a reduced risk of cross infection. Care Homes for Older People Page 6 of 9 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 27 18 The registered person must 30/06/2010 ensure that staff in post have a correct, detailed and clear job description for the role they undertake. This is required to ensure that staff are clear about their roles and responsibilities to ensure the health and welfare of people using the service. 2 27 12 The registered person must 30/06/2010 ensure that the amount of staff on duty are available in sufficient numbers to meet the dependency level of people using the service. This is needed to ensure that peoples needs can be met. Care Homes for Older People Page 7 of 9 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 19 The registered person is recommended to ensure that all areas of the home are clean and well maintained to ensure the safety of people using the service. The registered person is recommended to source alternative means of temporary staff to ensure that adequate resources are available in the form of agency staff from more than one source. The registered person is recommended to record of all staff who require supervision to include the dates they worked and who supervised them. This will provide a clear audit trail to ensure the safety of people using the service. 2 27 3 29 Care Homes for Older People Page 8 of 9 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 9 of 9 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
