Inspection on 06/06/06 for Elmsleigh Care Home

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elmsleigh Care Home 23/07/10

Elmsleigh Care Home 11/06/10

Elmsleigh Care Home 06/11/09

Elmsleigh Care Home 05/05/09

Elmsleigh Care Home 30/08/07

Elmsleigh Care Home 26/09/06

Elmsleigh Care Home 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 08:30 6 and 7th June 2006 th 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.V296006.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.V296006.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.V296006.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 18th January 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.V296006.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 two days on the 6th and 7th June 2006. The registered provider was available at the inspection on day one, and the acting manager was available on both days. Considerable time was spent at the inspection discussing the way forward for Elmsleigh as the situation at the inspection was unsatisfactory, in relation to a lack of nursing staff presently employed at the home. (The home has recently changed it’s registration to a care home with nursing). As requested by the CSCI agency nursing cover was arranged by the acting manager at the end of day two of the inspection and is now in place. During the course of the inspection the acting manager requested from the CSCI the documentation to register her as the manager of Elmsleigh. This will be positive for Elmsleigh as management arrangements to this point have been temporary. An action plan was agreed with the acting manager at the end of day two of the inspection. The expected outcomes of the action plan will be monitored by the CSCI over the next four weeks. What the service does well: The acting manager has responsibility for assessing all service users prior to admission to the home. She completes a good assessment prior to admission to include gathering written information from placing social workers and nurses. It was noted positively that the staff had time to sit with service users and walk in the grounds with the service users when they were experiencing some agitation. Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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.V296006.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.V296006.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): 1,2,3,4 and 5 The statement of purpose and service user guide are nearly completed ready to be issued to prospective and existing service users. A contract of care is provided to each service user/family which details the terms and conditions of their placement. A small amount of additional information is required for this document to meet the standard. 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. EVIDENCE: The statement of purpose document and service user guide have recently been reviewed and changed following the change of certificate of registration to a care home with nursing. Some small amendments are still to be made before issuing the documentation to existing and prospective service users. Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 9 The contact of care details the terms and conditions of the placement. It is recommended that the bedroom that the service user occupies is identified on the contract. A comprehensive pre admission assessment document has been prepared and is being used by the acting manager prior to any service user being admitted to the home. The acting manager also accesses important assessment information from nurses and social workers prior to admission. 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 users. Dementia training has recently taken place to all the staff at the home. It is recommended that this information/evidence be available in staff files. Service users (and their representatives) are encouraged to visit the home prior to admission. There is the most recent inspection report for visitors to read in the entrance of the home. Elmsleigh Care Home DS0000062005.V296006.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, There is some inconsistency in recording in care plans and this should be dealt with as a priority to ensure that the care needs of all the service users are evidenced as being met at all times. Medication administration records were found to be unsatisfactory on the day of the inspection. EVIDENCE: Each service user has a care plan in place that is problem based. A new system has been brought into the home to try and improve information being recorded on care needs. At this time there is variable information in place and this is related to the changes around the system. It was noted that there is also some inconsistencies around the recording of monthly reviews of the care plans. Service users (where able) should be encouraged to be included in regular care planning assessment. All the service users are registered with a general practitioner. Documentation is in place of multidisciplinary health care visits taking place to the service Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 11 users as required. Because there is inconsistency in the record keeping due to the change of system health care recorded information could again be improved. A discussion took place on continence assessments as it would appear at this time pad allocation does not meet needs. The acting manager has agreed to action continence assessments as a priority. On the day of the inspection a large number of gaps were found in the medication administration records which is unsatisfactory and included in this inspection report as a statutory requirement. At the inspection on the 18th January 2006 there were also a number of gaps in the medication administration records. All staff who have medication administration responsibilities must read the medication policy and procedure and have received training to ensure safe practice. Elmsleigh Care Home DS0000062005.V296006.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): 12,14 and 15 Consideration has been given to meeting the religious/spiritual needs of the service users. Daily records evidence when the service user has received a visitor. Staff were observed to help service users express a choice over their daily routines. Improvements have been made to the standard of meals at the home but records are not in place at this time. 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 comforting service users when they were confused/agitated. This in some cases involved just sitting with the service user and talking and in other cases having a walk around the pleasant grounds with them. The staff 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. Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 13 Some of the service users expressed very positive comments on the standard of the meals at the home. More choice of food has recently been provided at the home and drinks were noted to also be regularly provided (and available) during the course of the day. The main meal of the day is displayed and there are plans for each table to have a menu on their table. Cups of tea were available in china cups. An agency cook was in the home during the course of the inspection until the home is able to recruit a cook. Records of meals provided must be kept. Staff were observed asking service users what meals they would like. Elmsleigh Care Home DS0000062005.V296006.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 home has a satisfactory complaints policy and procedure but this important information has not been given to the service users. Evidence of staff receiving adult protection training must be available in staff files. EVIDENCE: The home has in place a complaints policy and procedure. This documentation should now be issued to each service users and or their representative. The home has an adult protection policy and procedure in place. It is appropriate for this important documentation to be reviewed to ensure that staff are aware of procedures at all times. Staff members watch a video on adult protection and the deputy manager then facilitates a questionnaire to confirm the staffs’ 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. Elmsleigh Care Home DS0000062005.V296006.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): The environmental standards were not formally assessed at this inspection. It is though noted that the registered provider is committed to meeting the environmental standards. On the day of the inspection improvements were noted to bathing facilities, general decoration and hand rails now in situ in corridors. EVIDENCE: Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30 Staffing levels in relation to qualified nursing staff were not satisfactory on the day of the inspection. This has now been addressed and is to be monitored by the CSCI over the next four weeks. Recruitments procedures of staff were found to be satisfactory. Staff require training in first aid as soon as is possible to ensure the safety of the service users. EVIDENCE: On the day of the inspection the acting manager informed the inspector of the recent difficulties that the home has experienced in recruiting qualified nurses. The home has recently changed it’s certificate of registration and there is now a requirement for a qualified nurse to be on duty at all times. At the time of issuing the new certificate of registration the home had recruited a number of nurses from overseas. These nurses are not now employed by the home. Following discussions with the registered provider and acting manager arrangements were made to staff the home with agency nurses until more permanent arrangements can be made. The staffing of the home is to be monitored by the CSCI over the next four weeks. The inspection of staff files evidenced that the correct recruitment procedures are being followed. Application forms are completed appropriately and two Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 17 written references are being taken up. In addition criminal records bureau checks are taking place. It is essential that staff have statutory training and at this time there are gaps in first aid training in particular to the night staff, this must be addressed. Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36 and 37 The acting manager at Elmsleigh is very experienced and supported well by the registered provider. Although the management standards assessed are not met at this time it is anticipated that significant improvements can be made to the running of the home in a short period of time. EVIDENCE: The acting manager has had until now responsibility for the running of two homes. This has resulted in her working limited hours at Elmsleigh. This situation is to be improved with her now employed full time and an application to be processed by the CSCI to register her as the manager. The registered provider is reminded of his statutory duty to provide to the CSCI regular monthly Regulation 26 reports. It is also requested at this Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 19 difficult time that the CSCI to receive a weekly report on the home for four weeks. There is evidence of staff supervision already taking place by the acting manager to the care staff and it is agreed that this will be prioritised to include supervision re adult protection issues and care planning recording. It is appropriate for all policies and procedures to be reviewed. Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 x x x x x x x x STAFFING Standard No Score 27 1 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 x x 2 2 x Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 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 OP27 Regulation 18 Requirement The registered person shall ensure that at all times suitably qualified, competent and experienced persons are working at the home. The registered person shall keep a record of all medicines kept in the care home for the service user, and the date on which they were administered to the service user. Timescale for action 30/06/06 2. OP9 17 30/06/06 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 OP1 OP2 OP4 Good Practice Recommendations To complete the service user guide and statement of purpose and make available to existing and prospective service users. To add to the contract of care the bedroom (number) that the service user occupies. To evidence in individual staff files the dementia training that the staff have recently received. DS0000062005.V296006.R01.S.doc Version 5.2 Page 22 Elmsleigh Care Home 4. OP7 To consistently record in care plans (on the same system) to evidence that the care needs of all the service users are being met. To carry out continence assessments as a priority. To keep a record of all meals provided at the home. To provide each service user (and or their representative) the complaints policy and procedure. To provide regular monthly Regulation 26 reports to the CSCI and for four weeks a weekly report. To update first aid training to staff with the aim of providing this cover at the home day and night, seven days a week. To evidence that staff are trained in adult protection policies and procedures. 5. 6. 7. 8. 9. OP8 OP15 OP16 OP37 OP30 10. OP18 Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elmsleigh Care Home DS0000062005.V296006.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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