Inspection on 18/01/06 for Elmsleigh Care Home

This inspection was carried out on 18th January 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

Elmsleigh Care Home 23/07/10

Elmsleigh Care Home 11/06/10

Elmsleigh Care Home 06/11/09

Elmsleigh Care Home 05/05/09

Elmsleigh Care Home 30/08/07

Elmsleigh Care Home 26/09/06

Elmsleigh Care Home 06/06/06

Elmsleigh Care Home 22/06/05

Elmsleigh Care Home 02/12/04

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

CARE HOMES FOR OLDER PEOPLE Elmsleigh Care Home Elmsleigh St Andrews Road Par St Austell Cornwall PL24 2LX Lead Inspector Elaine Bruce Unannounced Inspection 18th January 2006 08:15 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 Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elmsleigh Care Home Address Elmsleigh St Andrews Road Par St Austell Cornwall PL24 2LX 01726 812277 01726 814364 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) Robert Gregory Thomas Care Home 30 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (10) Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To admit two service users out of the normal age category of the home Total number of service users not to exceed a maximum of 30 Date of last inspection 22nd June 2005 Brief Description of the Service: Elmsleigh provides personal and social care for up to 30 older people, some of whom may be admitted in the category of dementia or 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. To the rear of the property there is a modern extension with most rooms having patio doors. There are sufficient bathrooms and toilet facilities in all areas and there are two dining rooms, lounges and dayrooms to meet the requirements of the service users. In the main house there is a stair lift to provide access to the first floor accommodation. Some of the bedrooms are only accessible to service users with good levels of mobility due to relatively steep stairs. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 18th January 2006 over six and a half hours and was carried out as an unannounced inspection. A tour of the premises took place and service users and staff were spoken to. All the service users expressed very positive comments about the standard of care that they are receiving at the home. Care records, staff files and policies and procedures were inspected. One of the part time deputy managers was on duty during the course of the inspection. The home is in the process of recruiting a new registered manager. In the interim period the Commission for Social Care Inspection has agreed that the registered manager of another home (within the same ownership) will cover temporarily part time at the home. What the service does well: What has improved since the last inspection? The content of the daily records have improved since the inspection of the 22nd June 2005. It is now noted that the daily records are good and complement the care planning documentation. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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 Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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 and 5 A contract of care is provided to each service user/family which details the terms and conditions of their placement. One of the deputy managers assesses all service users prior to admission to the home to ensure that the home will be able to meet their care needs. EVIDENCE: It is noted that the recommendation in the inspection report of the 22nd June 2005 has been addressed. The service user guide has been revised to provide prospective service users with details of what the home provides. Included in this documentation is a contract of care which is issued to each service user. The contract of care details the terms and conditions of the placement. It is recommended that the bedroom that the service user occupies is identified on the contract. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 9 A comprehensive pre admission assessment document has been prepared and is being used by the deputy manager(s) prior to any service user being admitted to the home. Service users (and their representatives) are encouraged to visit the home prior to admission. There is an inspection report available for visitors to read in the entrance of the home. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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): 7,8,9,10 and 11 The service user’s health, personal and social care needs are being met by the staff and multidisciplinary staff as required. The privacy and dignity of the service users is respected by the staff. This is confirmed by the positive comments re care that the service users gave to the inspector. Staff who administer medication are reminded of the importance of ensuring that medication records are at all times signed. EVIDENCE: Each service user has a care plan in place that is problem based to include information on social, health and psychological needs. Daily records support the care plans. The recording in the daily records is good and evidences that the care needs of the service users are being met. Evidence is in place that the care plans are being reviewed monthly. All the service users are registered with a general practitioner. Documentation is in place of multidisciplinary health care visits taking place to the service Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 11 users as required. Evidence is also in place of regular weighing of the service users. The home has in place a satisfactory medication policy and procedure to guide staff in safe administration. On the day of the inspection there were a number of gaps in the medication administration records which must at all times be completed in line with the policy and procedure. Some of the staff who administer the medication have received accredited medication training. The registered provider has advised the inspector that the rest of the staff (who administer) are due to receive this training. Included in care planning documentation is information in regard to respecting the privacy and dignity of the service users. All the service users spoken to during the course of the inspection expressed positive comments on the care that they are receiving by the staff. Information on the sensitive area of death and dying is included in assessment information on admission. Guidance is available in policies and procedures to staff to ensure that the care needs of the service user will continue to be met at this time. One of the deputy managers has undertaken training at the local hospice in this area and there are plans for more staff to receive this training. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14 and 15 Care planning documentation evidences that the social care needs of the service users are being met. Visitors are encouraged and welcomed into the home. Service users spoke positively about the standard of the meals being provided at the home. EVIDENCE: The care plan of each service users includes information on social care needs. The daily records supporting the care plans evidence that the identified social care needs are being met. The records also evidence when a service user has received a visitor and how they are spending their time. This could be for example watching the television or having a walk in the pleasant grounds of the home. The staffing levels allow the staff to spend one to one time with the service users (if required) to ensure that their social care needs are being met. There are plans in the summer for transport to be hired to allow the service users the opportunity of trips out of the home. It was noted that the religious/spiritual needs of the service users are not presently identified and it is recommended that this takes place. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 13 Visitors are welcomed into the home (mealtimes are discouraged) and are asked to sign the “visitors book” on arrival at the home. During the course of the inspection all the service users spoken to expressed very positive comments on the standard of the meals being provided. One of the cooks on duty was spoken to and she was able to provide evidence of all records required of the meals being provided at the home. On the day of the inspection the main meal of the day was beef stew and dumplings. Fresh vegetables were in the stew to include carrots and parsnips. A chocolate mouse with oranges was the dessert. The menu rotates over a four week period with an alternative choice always available should a service user not like the main meal. The menu is displayed for the service users and visitors to the home to see. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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 the following standard(s): 16,17 and 18 The home has a satisfactory complaints procedure provided to the service users in the service user guide. Information is available in the service user guide on the legal rights of the service users in the home. The home has in place adult protection policy and procedures and training to provide staff with the knowledge and understanding of adult protection issues to protect service users from abuse. EVIDENCE: The home has in place a complaints policy and procedure that has been issued to the service users in the service user guide. The complaints procedure is to be displayed on the notice board of the home. The service user guide has information for potential service users to advise them of their legal rights when in the home. The home has an adult protection policy and procedure in place. Staff members watch a video on adult protection and the deputy manager then facilitates a questionnaire to confirm the staffs’ knowledge of the issues. Following this a certificate is issued to confirm their competency. There are plans for staff members to receive adult protection training via the local social services department. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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): 19,20,21,22,23,24,25 and 26 The registered provider is committed to meeting the environmental standards. Evidence is in place of improvements to the premises in particular to some of the bedrooms at the home. EVIDENCE: The layout of the home is divided between the original old part of the house and the newer extensions. There is a stair lift to provide access to the first floor of the old house, but some of the rooms in this area require the service users to be able to negotiate some steep stairs. The newer extensions are more on the level, with ramps providing wheel chair access to all areas (apart from having to negotiate two stairs from the main building. It was noted that a particular area on the carpet of the main staircase of the home is worn out and a potential risk to the service users. The registered provider has since advised the inspector that this has been attended to. There are some very pleasant en-suite bedrooms in the new extension. Bedrooms generally have been personalised and refurbishment has taken place Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 16 to a number of bedrooms in the original part of the house. These rooms are looking very attractive. Some of the bedrooms have a pleasant outlook over the spacious grounds of the home. Car parking is available in the grounds of the home. Seating is provided in the grounds of the home and food is provided to encourage the birds into the grounds. The communal space within the home is of a good size with sitting, recreational and dining space for all the service users. There is a lounge and dining area in both the old and new parts of the home. There is also an additional smoking lounge. It is noted that this room does smell very strongly of smoke. Bathrooms are satisfactory but could be improved with a better layout for moving and handling the more dependent service users. During the course of the inspection it was noted that the foot guards on two wheelchairs had been removed and left in the corridor. The deputy manager was spoken to about this. It was agreed that an occupational therapy assessment would be appropriate. This is included in this inspection report as a good practice recommendation. It was also noted that a fire extinguisher had been removed off a wall presumably with a view to propping a door open nearby. This practice should be stopped. During the course of the inspection it was noted that the laundering of the bed linen is done to a high standard. The home was found to be very clean on the day of the inspection. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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): 27,29 and 30 Staffing levels are good allowing the staff to meet the care needs of the service users. Staff training is due to be updated to ensure that the staff have the skills to continue to meet the care needs of the service users. EVIDENCE: There are four care staff on duty in the morning with a deputy manager. This level of staffing is good as the occupancy levels at this time are not at full capacity. In the afternoon there are three carers with two waking night staff members employed. Cleaning staff are employed during the week and weekends. All staff are issued with contracts of employment. The inspection of staff files evidenced that the correct recruitment procedures are being followed. Application forms are completed appropriately and two written references are being taken up. In addition criminal records bureau checks are taking place. More staff training is planned to take place. It is recommended that consideration be given to first aid training as a priority as documentation in the home on the day of the inspection indicated that only one person has had this training. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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 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): 32,33,35 The deputy manager presented as very capable on the day of the inspection. She is fully aware of the planned changes to ultimately register a manager which is necessary to meet some of the standards that are presently not being met. EVIDENCE: The deputy (part time) manager on duty on the day of the inspection presented as very capable and is presently studying to obtain her registered managers award qualification. The home at this time is without a registered manger but the registered provider has plans for the post to be covered part time by a registered manager from another of his homes until the right candidate is found. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 19 At this time there are no staff meetings taking place at the home and it is recommended that this takes place as soon as is possible. In addition when appropriate a quality assurance monitoring audit should take place involving the service users and staff to meet standard 33. The registered provider visits the home regularly but it is noted that his monthly statutory reports (Regulation 26) are not available which must be addressed. Service users have separate records of all monies held on their behalf. Invoices and receipts are maintained and where possible the service users signs to acknowledge when they draw out cash. An audit can be carried out of all accounts. There is no staff supervision taking place at the home at this time. Policies and procedures are in place and up to date. They are generally required to be reviewed in April 06. Accident recording is completed satisfactorily. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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 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 3 8 3 9 2 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 2 3 2 2 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 2 2 x 3 2 2 x Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 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. 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. 1. 2. 3. 4. 5. 6. 7. 8. 9. Refer to Standard OP2 OP4 OP9 OP12 OP22 OP21 OP19 OP30 OP32 Good Practice Recommendations To identify in the contract of care the bedroom (number) that the service user occupies. To continue to provide dementia training to all staff to ensure that they are able to meet the care needs of all the service users admitted to the home. To ensure that at all times the medication administration records are signed. To identify and record the religious/spiritual care needs of the service users. To arrange for an occupational assessment re the foot guards on the service user wheelchairs. To review the bathing facilities at the home. To ensure that all fire extinguishers are in their place. To update first aid training to staff with the aim of providing this cover at the home day and night, seven days a week. To commence staff meetings which are minuted. DS0000062005.V268499.R01.S.doc Version 5.1 Page 22 Elmsleigh Care Home 10. 11. OP33 OP37 To carry out a quality monitoring audit of To provide regular monthly Regulation 26 reports to the CSCI. Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Elmsleigh Care Home DS0000062005.V268499.R01.S.doc Version 5.1 Page 24 - 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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