Inspection on 26/09/06 for Elmsleigh Care Home

This inspection was carried out on 26th September 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 06/06/06

Elmsleigh Care Home 18/01/06

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 Key Unannounced Inspection 26th September 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.V303958.R01.S.doc Version 5.2 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.V303958.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmsleigh Care Home Address Elmsleigh St Andrews Road Par St Austell Cornwall PL24 2LX 01726 812277 01726 815479 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 (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30) Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 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 6th June 2006 Brief Description of the Service: 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. 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.V303958.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection at Elmsleigh took place over one day on the 26th September 2006. The registered provider and acting manager were present at the home during the course of the inspection. The key inspection of the 6th and 7th June 2006 had identified serious concerns over unsatisfactory staffing levels re nurses at the home. This inspection identified that this situation has now stabilised with a number of nurses recently recruited by the home. The registered provider and acting manager have worked hard to address the staffing crises. The acting manager advised the inspector that she is nearly ready to send in her completed application form for her to become the registered manager of Elmsleigh. Time was spent with the service users and staff during the course of the day as well as the inspection of documentation. Observation of staff and service user interaction was positive as were comments from the service users about the standard of care that they are receiving at the home. What the service does well: What has improved since the last inspection? Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 Page 6 The staffing levels for nurses have improved considerably since the inspection of the 6th and 7th June 2006. The statement of purpose and service user guide are now completed ready to be issued to prospective and existing service users. First aid training has taken place to ensure that there is someone in the home at all times who has undertaken this training. 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.V303958.R01.S.doc Version 5.2 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.V303958.R01.S.doc Version 5.2 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): 1,3,4 and 5 The outcome for these standards was assessed as adequate. The statement of purpose and service user guide documentation have now been completed with information as required by legislation. The acting manager assesses all service users prior to admission to the home to ensure that the home will be able to meet their care needs. Visits to the home prior to admission are encouraged. EVIDENCE: The statement of purpose document and service user guide have recently been improved and updated following the change of registration at the home. A comprehensive pre admission assessment document is used by the acting manager prior to any service users being admitted to the home. The acting manager also accesses important assessment information from nurses and social workers prior to admission. Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 Page 9 The acting manager is fully aware of the importance of ensuring that staff have appropriate training to be able to meet the care needs of the service user. Dementia training has recently taken place to all staff at the home. It is recommended that this information/evidence be available in staff files and that generally all staff training evidence is fully in place. Service users (and their representatives) are encouraged to visit the home prior to admission. Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 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 outcome for these standards was assessed as adequate. Care plans are in place for each service user. Daily records that support the care plans are completed well but more information should be in the file on the lift history of each service user to help meet care needs in a client centred way. Observation of staff and service user interaction during the course of the inspection was very good. Staff were noted at all times to be kind and caring. Medication administration records were found to be unsatisfactory on the day of the inspection. This was also noted in the inspection report of the 6th and 7th June 2006. More attention should be given to recording the wishes of the service users’ re death and dying. EVIDENCE: Each service user has a care plan in place that is problem based. There is evidence in place that the care plans are being reviewed monthly. The care Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 Page 11 staff are involved in the daily recording and these records are completed well. The home operates a key worker system. Attention should now be given to improving the information on the life history of each service user to allow care to be given in a client centred way. All of the service users are registered with a general practitioner. Documentation is in place of multidisciplinary health care visits taking place to the service users as required. Community nursing staff have taken responsibility for assessing the continence needs of the service users. It was identified on the inspection of the 6th and 7th June 2006 that there were a large number of gaps in the medication administration records. It is noted again that this has not yet been addressed. It is appropriate for the medication policy and procedure to be updated and for all the new nursing staff to read and sign this documentation. The acting manager carries out a regular audit of medication administration. Staff may require additional training re record keeping. More attention should be given to the recording of the wishes of the service users re death and dying. Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 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 The outcome for these standards was assessed as good. Consideration has been given to meeting the social care needs of the service users. Daily records evidence when the service user has received a visitor and taken part in an activity. Staff were observed to help service users express a choice over their daily routines. Service users spoke positively about the standard of the meals at the home. It was noted that breakfast at the home was a very positive time with a choice over the time of the meal and a choice of breakfast being provided. EVIDENCE: Once a fortnight the home provides music that is aimed at meeting spiritual needs in a comforting way. Once a month a Lay preacher attends the home to meet religious needs. It was noted during the course of the inspection that the staff were able to spend time with the service users. This in some cases involved just sitting with the service users and in other cases feeding them for example. The staff Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 Page 13 were observed encouraging service users to make choices about how they spend their day at the home. Daily records evidence when a service user has received a visitor and taken part in an activity which also includes one to one time. All visitors to the home are asked to sign the visitors’ book in the entrance of the home. Some of the service users expressed very positive comments on the standard of the meals at the home. A choice of meals is available at all times and this information is available in the home for the service users and visitors to see. All records of meals provided are documented and all drinks given are also documented. Breakfast was observed to be a very positive experience. It took place over two hours with service users being able to chose what time they wish to eat and what they wish to eat, to include a cooked breakfast should they so wish. The home employs two cooks who have appropriate qualifications. Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 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 and 18 The outcome for these standards was assessed as adequate. The home has a satisfactory complaints policy and procedure provided to the service user and or their representatives in the service user guide. The home has guidance on adult protection but more information is required on local procedures. EVIDENCE: The home has a satisfactory complaints policy and procedure provided to the service user and or their representative in the service user guide. The home has an adult protection policy and procedure in place. As identified in the inspection report of the 6th and 7th June 2006 this important documentation should be reviewed to ensure that the staff are aware of procedures at all times. All staff are encouraged to watch a video on adult protection and then a questionnaire is completed to confirm their knowledge of the issues raised. Following this a certificate is issued to confirm their competency. It is noted that there are gaps in the files in relation to this evidence. It is also recommended that external adult protection training takes place. Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 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 The outcome for these standards was assessed as adequate. The registered provider has on going plans to improve the premises at Elmsleigh and evidence is already in place that work has commenced to generally upgrade the premises. EVIDENCE: Accommodation provided at Elmsleigh is either in the older part of the home or a more recent purpose built extension. Bedrooms and communal accommodation is provided in both parts of the home. The grounds at the home are very spacious and attractive, with car parking available in the grounds. The home has recently changed ownership and evidence is in place of improvements to the premises. This includes for example new carpets and immediate improvements to toilet and bathing facilities for example. Hand rails have been added to corridors and a lift to enable wheel-chair users access Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 Page 16 from one part of the home to the other. A staff member is employed for maintenance duties. A staff member is employed for cleaning duties. He was spoken to during the course of the inspection. The home was found to be clean on the day of the inspection. Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 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): 27,28,29 and 30 The outcome for these standards was assessed as adequate. Staffing levels were found to be satisfactory on the day of the inspection. The home has recently recruited a number of qualified nurses to address the staffing problems identified in the previous inspection report. Recruitment procedures for recruiting staff are satisfactory. More staff training to meet the requirements of legislation is needed and more evidence of training undertaken is required for the staff files. EVIDENCE: On the day of the inspection staffing levels were as per the staffing rota. The home has worked hard recently to recruit qualified nurses and the nurses spoken to during the course of the inspection presented well. An inspection of staff files evidenced that the correct recruitment procedures for employing staff 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. It is essential that staff have statutory training. The inspection report of the 6th and 7th June 2006 identified that staff did not have first aid training to provide appropriate cover for the home. This has now been addressed but fire Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 Page 18 drill training is also required as a priority. Where any training has taken place it is recommended that evidence is provided in the staff file at all times. It was noted that a senior member on duty at the time of the inspection was undertaking induction training to staff. The home has employed full time administration help to enable the acting manager to concentrate more on her duties and responsibilities. Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 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): 31,33 and 38 The outcome for these standards was assessed as adequate. Elmsleigh is without a registered manager at this time and this paper work is anticipated soon by the CSCI. The registered provider is supportive and attends the home regularly but is reminded of the requirement for Regulation 26 reports. It is with credit to the registered provider and acting manager that the staffing crisis at Elmsleigh has been addressed and further work can now take place on meeting the National Minimum Standards. EVIDENCE: The acting manager until recently has had responsibility for running two homes. She is now at Elmsleigh full time and an application to register her formally as the manager is anticipated by the CSCI. She has worked well at Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 Page 20 the home (with the support of the registered provider) during a very difficult time. This crises period would appear to be over with the correct amount of qualified nursing staff on duty at the home at this time. The registered provider attends the home regularly but he is reminded of his statutory duty to provide to the CSCI regular Regulation 26 reports. The home have recently sent out questionnaires to service users/representatives for quality assurance purposes, this information will be assessed for quality monitoring purposes. It is appropriate for all policies and procedures to be reviewed to include all health and safety policies and procedures. Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 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 3 x 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 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 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x x x 2 Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 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. 1. Standard OP30 Regulation 23(4)(d) Requirement The registered person shall after consultation with the fire authority make arrangements for persons working at the care home to receive suitable training in fire prevention. Timescale for action 31/12/06 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. Refer to Standard OP4 OP7 OP9 Good Practice Recommendations To provide evidence of all training that staff have undertaken. To gather more information on each service user: (life history) to help deliver care in a client centred approach. To ensure that at all times the medication administration records are signed. To ensure that all the nursing staff have read the medication policy and procedure. To include more information in documentation on the wishes of the service user re death and dying. 3. OP10 Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 Page 23 4. OP18 To ensure all guidance on adult protection is up to date and all staff are trained in this important area to ensure the safety of the service users at all times. 5. OP37 To provide regular monthly Regulation 26 reports to the CSCI. 6. OP38 To review all policies and procedures in the home to include all health and safety policies and procedures Elmsleigh Care Home DS0000062005.V303958.R01.S.doc Version 5.2 Page 24 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.V303958.R01.S.doc Version 5.2 Page 25 - 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. 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