Inspection on 30/08/07 for Elmsleigh Care Home

This inspection was carried out on 30th August 2007.

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 26/09/06

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 Lynda Kirtland Unannounced Inspection 30 and 31st August 2007 9:15 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.V344679.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.V344679.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 Mrs Susan Windsor vacant post Care Home 43 Category(ies) of Dementia (43), Mental disorder, excluding registration, with number learning disability or dementia (43) of places Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 43 places Mental disorder, excluding learning disability or dementia - Code MD - maximum 43 places The maximum number of service users who can be accommodated are 43. 26th September 2006 2. Date of last inspection 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. The home is situated in Par, approximately three miles form the town of St Austell. Service users’ private accommodation is set out across two floors in the main house. 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. All of the bedrooms are for single occupancy and there are sufficient bathing facilities. The new extension 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 new extension service users 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 registered manager confirmed during the inspection that the range of fees is £330.00 to £725.00 per week. Toiletries, newspapers and certain activities are the financial responsibility of the service user. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited Elmsleigh for an unannounced key inspection on the 30 and 31 August 2007. It lasted for approximately fourteen hours. Information about the home received by the Commission since the previous inspection was taken into account when planning the inspection. The purpose of the inspection was to ensure that residents’ needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. This involved interviews with service users living in the home and visiting relatives and observation of the daily life and care provided. There was an inspection of the home’s premises and of written documents concerning the care and protection of service users and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with some members of the management team. One method used was case tracking, of which three service users were selected. This involves examining the care notes and documents for a select number of residents and following this through with interviews with them or their relatives and staff working with them. This provides a useful, in-depth insight as to how residents’ needs are being met in the home. In discussions with residents they commented positively about the care they receive from staff, such as: ‘its marvellous here’, ‘nothing is too much bother for staff’, ‘they (staff) are all so caring’ and ‘they (staff) can’t do anything to improve this service’. What the service does well: Residents are admitted to the home on the basis of an assessment so that they can be confident that it will be suitable to meet their needs. Residents commented that staff ‘lessened my anxiety by being so welcoming when I moved here’. Most residents are admitted to the home on a permanent basis, often following a “trial” period, when they stay for a short time to see if they like it before committing to permanent admission. All of the residents interviewed during the inspection confirmed that they are well cared for and treated with respect at all times and this was observed during the inspection. All residents have a detailed care plan, which guide, inform and direct staff as to what caring interventions are needed to provide consistent care for residents. Documentation confirmed that the care plans were reviewed on a regular bases. All residents confirmed that they felt their care needs were met to a ‘good’ or ‘high’ standard. All residents were satisfied with health provision Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 6 and felt that this was accessed when needed. Medication is administered safely. All of the residents interviewed said that they enjoy the food provided to them. The inspector was invited by residents to join them for a meal that was a social and unrushed occasion. Residents commented the food is “first class” and were aware of the choices of menu for that day. Food is prepared on the premises, using mainly fresh, locally sourced ingredients and served in attractive surroundings. Residents can take meals in their own rooms if they prefer or in the dining area. The home was clean, tidy and pleasant throughout at the time of the unannounced inspection. Domestic staff, nursing and care staff are on duty to meet residents’ needs safely. Residents felt that staff were ‘busy’ but confirmed that staff responds quickly to the call system. There is more than the recommended minimum number of qualified care staff so that residents can be confident of their knowledge and competency. They are recruited fairly and on the basis that they are suitable and safe to work with vulnerable people in a care setting and undergo regular, ongoing training to update their knowledge and skills. The home is well managed, for the benefit of the residents. The registered provider visits the home weekly and the registered manager is in active, dayto-day charge of the home. Between them they have the qualifications, knowledge and experience necessary to operate the home and business effectively. Residents’ financial interests are protected and most manage their own affairs or do so with the assistance of their relatives. Records are held in the home to ensure residents’ welfare and protection. They are securely stored so as to protect their confidentiality. Residents are able to access their personal records if they wish. What has improved since the last inspection? The requirement and most of the recommendations that were identified at the previous inspection have been complied with. Staff have received fire, adult protection and dementia training and evidence of training is now available. The contract of care provided to each resident, which stipulates their terms and conditions of the placement now specify the Service users bedroom number that they will occupy. The registered manager stated that there have been many improvements to the service since the last inspection, which were observed and confirmed by staff and residents during the inspection as follows: • The staff ratio will be increasing in September 2007 with an extra nurse on duty. Staff and residents commented that they feel there is sufficient Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 7 • • • • • • • • • • • staff on duty and residents in particular commented that staff respond to call bells promptly. New fire system installed New laundry area and equipment New kitchen New call system installed Doors are alarmed so that they are more aware of residents whereabouts in the home Residents are more involved in the choice of décor, especially in the new extension. New cook has resulted in residents and staff complimenting the quality, quantity and choice of meals, residents saying the food is ‘first class’ A newsletter of what is occurring in the home has been introduced Residents meetings have commenced so that consultation with residents has improved further Residents are more involved in the choosing of activities All residents have care plans. What they could do better: Residents and relatives all said that they could not think of any improvements that could be made to the facilities or care that they receive at Elmsleigh. Staff echoed this, saying they ‘enjoy working here’ and that managers are ‘really supportive’. No statutory requirements were identified at this inspection. Recommendations to improve care practice further were identified at this inspection as follows: • That resident and their representatives views at their admission assessment, in their care plan and subsequent reviews are recorded. • That the registered manager continues to monitor on a monthly bases the medication systems to ensure that when medication is administered that staff are completing records accurately. In addition that she continues to address the issue re PRN medication and ensure that the medication in the home tallies with medication records. • That when transcribing medication this is witnessed by two staff members • That findings of the Quality assurance system is sent to the Commission • That team meetings commence • That the adult protection policy and the homes general policies and procedures are reviewed and updated. • The registered manager completes her Registered Manager Award. The inspector would like to thank residents, relatives, visitors, staff and the management team for their kind assistance during this inspection process. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 9 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.V344679.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3, 4,5 Elmsleigh does not provide intermediate care as set out in standard 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A contract of care is provided to Service users so that they are aware of their rights whilst resident at Elmsleigh. The needs of prospective service users are assessed prior to admission so that they can be assured that the home can provide adequate care and meet their individual care needs. Service users are invited to meet with staff and visit the home that will assist them in making the decision about living at Elmsleigh. EVIDENCE: Managers from the home visit prospective residents and complete a needs assessment, which takes into account service users physical, emotional, social and diverse, needs. All the residents’ records case tracked contained needs assessments completed by the home’s managers. These assessment records recorded their assessed needs in detail and included their views and preferences. The home’s assessment does not make clear who was present at the assessment. This would provide evidence that the prospective resident and their family, or representatives, were involved in the assessment to ensure that their diverse needs were recorded. Residents and relatives did, however, Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 11 feel that the home involved them in the resident’s care arrangements. Records from relevant professionals are also gained as part of the assessment process. A contract of care is provided to each resident which stipulates their terms and conditions of the placement. This now specified the Service users bedroom number that they will occupy as recommended at the last inspection. Since the previous inspection all staff have attended dementia training. As the home is currently in the process of extending its service by another five bedrooms, the Statement Of Purpose and Service Users guide was not inspected on this occasion, as it will need to be amended to reflect these changes. Residents however did comment that they received written information about the home prior to or on admission. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Written care plans direct and inform staff about the Service users’ health and personal care needs so that these can be consistently met. The healthcare needs of Service users are monitored and addressed so that their needs are met. The arrangements for the management of medicines protect service users. Service users’ are treated respectfully at all times so that they retain their dignity and enjoy a good quality of life in the home. EVIDENCE: All the residents’ case tracked had written care plans. These were satisfactory but it was noted that dependent on the assessor they varied in the amount of detail in guiding staff as to what interventions are needed to provide consistent care to the individual resident. The Personal Routines and Preferences records detail residents’ lifestyle preferences and choices, their dietary preferences and needs, and their religious beliefs. These care plans were dated and evidenced records of regular reviews. It is recommended that when residents or their representatives are consulted in the care planning process that this is recorded so that the home can evidence their participation more fully. Risk assessments for example in respect of mobility are completed and inform staff as to what interventions and equipment is needed to assist in the moving Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 13 of an individual. The risk assessments were completed to a satisfactory standard with some providing more detailed information. The daily records for residents summarised if care had been provided that day and is audited monthly by the registered manager. These records confirm the care that the resident have experienced during the day plus any activities that they have participated in. Residents are registered with local GP practices. Residents felt that their health care needs were monitored and attention obtained promptly when needed. Residents are weighed regularly. For the residential residents at the home if they are receiving care form the district nurses they complete their own paperwork that is left at the home. Medicines are stored in a locked medicines trolley and stored securely. The medication trolley was tidy and well organised. The Monitored Dose System (MDS) is in use. Since the previous inspection the registered manager has undertaken monthly monitoring of medication to ensure that it is being received, administered and that records are accurate. This inspection identified that in the main this was being done. There were two incidents noted in the last month where medication on one day had not been administered but signed as given. The registered manager will look into these incidents. The registered manager was aware that records of PRN medication, which is loose, had not been corresponding with tablets held in the cupboard and was already addressing this issue. When transcribing medication two staff members should witness this. Due to the registered manager being aware and already addressing theses issues a recommendation has been identified and this will be reviewed at the next inspection. Residents and their relatives made positive comments on the skills and caring qualities of staff. Residents felt well cared for and reported that staff delivered care sensitively, respected their privacy and dignity and listened to their concerns. Residents said that staff were “lovely” and “kind”. Residents felt safe when staff assisted them with personal care. Examples of staff providing skilled and sensitive care were observed during the inspection. Residents found it difficult to identify any area where the home could improve. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported in a lifestyle, which accords as far as possible with their own expectations and preferences. A range of activities takes place that meets residents’ social, religious and recreational interests, following the introduction of residents meetings more activities will be provided. A newsletter has been introduced The diet provided is varied and nutritious with attention to individual preferences EVIDENCE: Residents felt that they had control over their daily lives and were supported to make choices about their routines and activities. The majority felt that there was ‘enough to do’. The younger residents at the home said they would like more activities provided such as art, keep fit or going bowling and were unaware of the recent decisions made at the residents meeting where a sports club, camera club and film club is being introduced. They were pleased to hear of theses new ventures. These new clubs were being promoted in the homes newsletter, which was printed during the inspection. Residents’ care plans detail their social and activity interests. The home provides a range of planned activities. This includes a Christian service, outings, music and hairdressing. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 15 Residents and visitors reported that they found the visiting arrangements open and flexible. They felt that visitors were made welcome. Residents choose where they meet their guests. Residents’ finances are managed with informal assistance from relatives. Residents confirmed they have a lockable facility for small items of value. Residents can bring in possessions and furniture at admission by agreement with the provider. Many residents and their families had personalised their bedrooms. Residents were aware that they could lock their rooms if wished, but have chosen not too. The inspector was invited by residents to join them for lunch, which was a social and unrushed occasion with staff providing sensitive support in a pleasant manner. There was a choice of lunch, and if residents felt unable to eat main meal a ‘snack’ lunch was offered to them. The meal was to a high standard and residents said that with the appointment of the new cook the standard of and variety of food had risen and they only had compliments about the quality, quantity and choice of food now available. Residents’ comments include: ‘first class’, ‘excellent’, and ‘good’, ‘very tasty’. They confirmed that they were aware of the meals provided each day. Each resident’s preferences and choices are recorded. Breakfast can be taken in the dining area or in the resident’s room and residents were very happy with the choices available. Staff knew residents’ likes and dislikes. Hot and cold drinks are served between meals. The chef said he would be preparing menus for residents use. The Chef is providing a few residents with soft meals at present and diets for residents with diabetes. The Chef exceeds food and hygiene qualifications as outlined in the national minimum standards and has over 20 years experience in the catering industry. The chef prepares lunch, tea and supper meals from Monday to Saturday. Care staff prepares breakfasts and separate staff undertake the cooking duties on Sundays. The chef demonstrated an awareness of resident’s likes/ dislikes of food and any special dietary requirements. The kitchen has recently been refurbished. A recent environmental health inspection identified some minor issues i.e. new fly mesh on windows, which has since been ordered. Records of fridge/ freezer temperatures are being kept and it is recommended that all information relating to food be recorded in the same location of the ‘safer food better business’ document to avoid duplication. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are arrangements to protect service users from abuse. EVIDENCE: The complaints procedure is appropriate. Residents said that if they had any issues of concerns, or ideas for improving the service that they were able to approach the management team and felt that they would be listened too. Residents have access to a summary of the process of how to voice concerns via the Service Users guide and posters on display plus the introduction of residents meetings. No formal complaints have been received since the last inspection. The home has received a number of compliments recently. The registered manager agreed to review the homes adult protection policy and procedure to make it clearer in what actions staff must take when they are alerted to or have a suspicion of abuse. The registered manager has attended the Multi Agency Adult protection training (alerter, investigators and foundation course) and is aiming to cascade this training to the staff team. The home had a copy of the Cornwall Multi-Agency Adult Protection Guidance and the Alerter’ Guidance. Staff were aware of their responsibilities to report concerns about the protection of vulnerable adults. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is accessible, well maintained and safe. The premises are clean and hygienic providing a pleasant environment and reducing risks to residents. The lighting in the corridor should be improved. EVIDENCE: The home was clean and tidy and pleasant throughout at the time of the unannounced inspection. Residents commented that the home was ‘comfortable’, furnishings were ‘good standard’ and they could not think of any improvements in this area. They were all happy with their individual rooms saying it is ‘lovely’ and confirming they had chosen the furnishings. The home benefits from a variety of communal spaces so that residents have a choice to sit in a variety of lounges (6) and can see visitors in private in these areas or their own room. Residents were observed to be using these areas at the time of inspection and also the garden (10 acres). Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 18 Since the previous inspection the registered provider has decorated rooms, brought new furniture and during the inspection new carpets were being fitted. Service users said that they were ‘pleased’ with the furnishings in the home. Toilet areas have been refurbished and disabled toilet facilities are now available. New adjustable beds have also been purchased. The registered manager acknowledged that some areas in the main house, such as bathrooms, need to be redecorated. However they are functional and clean. A new laundry area has just been completed. Building works are continuing at the home and the domestic staff are to be congratulated in how they are managing to keep the home so clean during these works. Residents and visitors also commented on this. During this inspection staff were aware of the importance of infection procedures. The home employs domestic staff to ensure that the home is kept clean and staff have training in infection control to protect service users from the risk of infection. One lounge did have a slight odour but this was being addressed during the inspection. The lighting in the corridor of the new extension needs to be reviewed as currently with the lights on the area is still dark and makes it difficult, especially for those with a visual impairment to negotiate this area safely. The registered manager was advised by building regulations of the wattage that by legislation was to be installed in this area, but the area is still too dark and therefore must be reviewed. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is suitably staffed to meet residents’ needs safely. Staff are qualified and competent to work with the residents. They are recruited on the basis of fair, safe and effective recruitment and selection policies and practices. Improvements are needed to ensue that all recently recruited staff have relevant checks made before commencing employment. They have good access to ongoing training to maintain their knowledge and skills. EVIDENCE: Staff are employed in a variety of capacities for the smooth running of the home. There are two nurses, seven carers plus the management team on duty during the day. In the evening 2 nurses plus seven carers remain on duty, and at night 2 nurses plus four carers and twilight are on duty. The registered manager has reviewed staffing levels and believes this level of staffing is able to safely meet residents’ needs. In addition there are sufficient domestic, catering and maintenance staff on duty. Rotas confirmed this level of staffing. Staff commented, echoed by residents that they felt there was sufficient staff on duty. Residents said that staff responded to call bells promptly. On the first day of inspection one unit did have staff sickness and so they were down on staffing levels. By lunchtime staffing levels had been resumed to that of the rota as a member of staff covered an extra shift. Staff in this unit said that whilst they were short staffed the work was prioritised in the morning until the Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 20 extra cover was available. Staff and residents felt this was managed well and did not express any concern regarding this. The registered manager said that from the 17 September there would be an increase in nursing staff to three nurses on duty during the day/ evening plus seven carers and the management team. This will allow the registered manager to have more dedicated management time and share the on call nurse system more fairly. Over 50 of care staff have achieved a minimum of NVQ at level 2 and the remainder are working towards achieving qualifications at NVQ level 2 or3 in care, so that residents can be confident of the competency of the people looking after them. The home’s recruitment policy is robust and sets out how staff are fairly and safely recruited, in accordance with good equal opportunities. From inspection of newly recruited staff the relevant documents were present. There is a staff-training plan for the home, which sets out training staff have had and are expected to undertake, so that they maintain their knowledge and skills. Staff members commented that there is good access to training and that they have found the training beneficial. Staff were observed to be skilled in their interaction with residents. Residents were complimentary about staff: ‘cheerful’, ’kind’ ‘nothing too much bother’ to name a few comments. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36,37 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an experienced and qualified management team who have a sound understanding of their responsibilities. The home is well run and managed for the benefit of the residents. Quality assurance processes demonstrate that service users their representatives, and staff are consulted about the service that the home provides. Records are maintained and handled in accordance with good practice, for the welfare and safety of the residents. The health and safety of residents and staff are promoted and protected. The homes policies and procedures need to be reviewed to ensure they accurately inform staff of their accountability and the homes expectations of them. EVIDENCE: The registered provider visit the home on a weekly bases and has commenced completing regulation 26 reports which demonstrate that he has a over view of the service, its strengths and areas for improvement. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 22 The registered manager is in active day-to-day control of the management of the home. The registered manager is suitably qualified, skilled and competent to run the home effectively and do so for the benefit of the residents. The registered manager must complete the Registered Managers Award and has enrolled to commence this. Staff and residents commented positively about the registered manager and all stated they felt able to approach the management team with ideas of improvements to the service, or if they had any concerns. The registered providers do not act as agents or appointees for any of the residents. Most of the current residents manage their own financial affairs or do this with the assistance of their relatives or representatives. The home will from petty cash lend residents money and then invoice family for the loan, appropriate receipts and records are kept of these transactions, although they were not inspected in detail on this occasion. A quality assurance system is in place. Monthly monitoring of care plans, medication, and maintenance are undertaken. Relatives are invited to care plan reviews, and the management team are available to relatives and visitors. The registered manager has sought the views of residents and their representatives. Feedback from this was very positive. The registered manager agreed to forward a copy of their quality assurance findings and action they are taking to the Commission. Residents’ meetings have just been introduced and the registered manager was pleased to learn that staff are now saying that they would like staff meetings to commence as this has been an area of reluctance previously. The records showed that staff receives regular supervision. Staff reported that informal and formal supervision supported them to do their jobs well and they had confidence in the management. Staff felt that the home provided a very high quality of care and they worked well as a team to achieve this. Records reviewed at this inspection indicate that they are appropriately maintained and held, to ensure the welfare and safety of residents. The handover records were discussed to ensure that in future they are in line with the requirements of the data protection act and promote confidentiality. There are suitable storage facilities and records are kept in ways that protect their confidentiality. The homes policies and procedures need to be reviewed to ensure they accurately inform staff of their accountability and the homes expectations of them. Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 23 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 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X 3 3 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 X 3 3 2 Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 24 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. 1. Refer to Standard OP7 OP3 Good Practice Recommendations That Service users and their representative’s views at their admission assessment, in their care plan and subsequent reviews are recorded. That the registered manager continues to monitor on a monthly bases the medication systems to ensure that when medication is administered that staff are completing records accurately. In addition that she continues to address the issue re PRN medication and ensure that the medication in the home tallies with medication records. And that when transcribing medication this is witnessed by two staff members To continue the process of gathering more information on each service user: (life history) to help deliver care in a client centred approach. DS0000062005.V344679.R01.S.doc Version 5.2 Page 25 2. OP9 3. OP7 Elmsleigh Care Home 4. 5 OP18 OP19 To review the adult protection policy and procedure and ensure that this information is cascaded to staff. The lighting in the corridor of the new extension needs to be reviewed as currently with the lights on the area is still dark and makes it difficult, especially for those with a visual impairment to negotiate this area safely The registered manager completes her Registered Manager Award. That findings of the Quality assurance system is sent to the Commission To review all policies and procedures in the home to include health and safety policies and procedures 6 7 8 OP31 OP33 OP38 Elmsleigh Care Home DS0000062005.V344679.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V344679.R01.S.doc Version 5.2 Page 27 - 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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