Inspection on 22/06/05 for Elmsleigh Care Home

This inspection was carried out on 22nd June 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

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 18/01/06

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 St Andrews Road Par St Austell Cornwall, PL24 2LX Lead Inspector Elaine Bruce Announced 22 June 2005 08.15 a.m. 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. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 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 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) registration, with number Mental 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 D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NO Date of last inspection 2nd December 2004 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 D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 22nd June 2005 over seven hours and was carried out as an announced inspection. A tour of most of the premises took place and service users and staff were spoken to. Care records, staff files and policies and procedures were inspected. The registered provider was present during the course of the inspection. This is the first inspection with the registered manger now in place following recent change of ownership of the home. What the service does well: What has improved since the last inspection? What they could do better: Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 6 The registered manager has worked hard for this announced inspection but some management tasks will have to be delegated to allow standards to be met and continue to be met. For example staff supervision cannot be achieved by one person over the course of the year. 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 D52-D04 S62005 Elmsleigh V222729 220605 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 Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 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 and 4 The home’s statement of purpose is complete. The service user guide is being revised and when finalised will provide prospective service users with details of what the home provides helping an informed decision about admission to the home. The manager or assistant manager are involved in the service user pre admission assessment procedure to ensure that the home will be able to meet their care needs. EVIDENCE: The home has a statement of purpose document in place that meets all the requirements of The Care Homes Regulations (2001). The statement of purpose document is available in the home. The service user guide is presently being revised to include additional small pieces of important information for example: lockable storage space is available if required and that visitors to the home are asked to sign in the visitors’ book. When completed this documentation will be available for each service user and all potential service user admissions to the home. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 9 A comprehensive pre admission assessment document has been prepared and is being used by the manager or her assistant manager prior to any service user being admitted to the home. The registered provider and registered manager are fully aware of the importance of ensuring that staff have appropriate training to be able to meet the care needs of the service users. Dementia training is presently taking place and the plan is that all staff will be trained in this specialised area. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 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 and 9 The service user’s health, personal and social care needs are being met by the staff and multidisciplinary staff as required. Medication is being administered correctly to the service users. EVIDENCE: The care planning documentation system has recently been revised and a considerable amount of work has taken place in this area. 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. Evidence is in place of monthly reviews of the care plans taking place. Some good practice recommendations for care planning were made at the inspection and include for example reviewing the content of the daily recording. All the service users are registered with a general practitioner and working relationships are being built with community nurses and other health care professionals. Documentation is in place of multidisciplinary health care visits taking place to the service users as required. Evidence is also in place of regular weighing of the service users. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 11 The home has in place a satisfactory medication policy and procedure to guide staff in safe administration. Medication administration records were found to be completed appropriately on the day of the inspection as was the storage of the medication. Staff who administer the medication have received some medication training, but the training they receive is now to be accredited. The manager has agreed to access a college for this training to take place. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 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) These standards were not assessed at this inspection. EVIDENCE: Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 The home has a satisfactory complaints procedure provided to the service users in the service user guide. 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 home has an adult protection policy and procedure in place. Staff members watch a video on adult protection and the manager then facilitates a questionnaire to confirm the staffs’ knowledge of the issues. Following this a certificate is issued to confirm their competency. The manager has worked hard in this area of staff training and has further plans for staff members to receive adult protection training via the local social services department. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 Changes to the environment at Elmsleigh are taking place to include the pending registration of new en suite bedrooms. 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 2 stairs from the main building). It is recommended that this information be included in the service user guide. There are some en-suite bedrooms in the new extension that are in the process of being registered. A satisfactory inspection of the premises by the fire officer took place on the 21st June 2005. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 15 The communal space within the home is of 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. Furnishings in the communal rooms are adequate, homely and domestic in nature. Seating areas are provided in the grounds of the home. The grounds are very pleasant and spacious, Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 27,28,29 and 30 Staffing levels are good allowing staff to meet the care needs of the service users. Staff training is very much encouraged by the registered provider and the registered manager and is ongoing. EVIDENCE: There are five care staff on duty in the morning which 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. All staff are issued with contracts of employment. The registered manager is actively encouraging staff to undertake NVQ training. Six staff members have obtained an NVQ 2 in care with two other staff registered to undertake this training. The assistant managers have qualifications at level 3 NVQ. 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. Training is ongoing and is a priority to the registered manager. Statutory fire drill training is due to take place as is first aid training. Moving and handling training has taken place and staff are waiting to be issued with certificates. Dementia training is ongoing with plans for all staff to receive this training. Six Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 17 staff are undertaking infection control training and the community nurses have offered to provide the staff with continence training. New staff members receive an induction training that is based on good practice recommendations to include the principles of care. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 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) 31,34 and 35 The registered manager has worked hard for her first inspection. The support of her senior staff will allow her to continue to improve standards to the benefit of the service users. EVIDENCE: The manager has recently been registered by The Commission for Social Care Inspection. She is working very hard to meet The National Minimum Standards. She is supported in her duties by the registered provider who visits the home approximately two or three days a week. She is also supported by two senior staff members who have each been given specific roles and responsibilities. More duties and tasks will need to be delegated (for example staff supervision) to allow standards not assessed to be met and to continue to meet those already assessed as met. Positive comments were given (to the inspector) about the manager from the staff during the course of her inspection on her management style. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 19 The registered provider has very recently purchased the home and The Commission for Social Care Inspection took up financial references which were found to be satisfactory. The home has made rapid and significant progress with regard personal accounts and service users have separate records of all monies held on their behalf. Invoices and receipts are maintained and where possible the service user signs to acknowledge when they draw out cash. An audit can be carried out of all accounts except it is recommended that for one service user a “residents account” is opened to allow her to earn interest on the money that is accumulating at the home. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 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 2 x x 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x x x x x 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 Standard No 16 17 18 Score 3 x 3 3 x x 3 2 x x x Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 21 NO 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 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. Refer to Standard 1 4 7 9 19 35 Good Practice Recommendations To revise the service user guide and include all helpful information as discussed at the time of the inspection. 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 review the content of the daily recording to ensure that it complements the care planning. All staff who administer medication should receive accredited medication training. To add to the service user guide information on stairs that may have to be negotiated in the home. To open a bank account on behalf of a service user to allow her to earn interest on the money that is accumulating in the home. Elmsleigh Care Home D52-D04 S62005 Elmsleigh V222729 220605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 D52-D04 S62005 Elmsleigh V222729 220605 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. 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!