Inspection on 08/11/05 for Elmstead

This inspection was carried out on 8th November 2005.

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

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

Other inspections for this house

Elmstead 09/05/07

Elmstead 16/05/06

Elmstead 24/05/05

Elmstead 18/01/05

Elmstead 27/09/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Elmstead Elmstead 104 Elmstead Lane Chislehurst Kent BR7 5EL Lead Inspector Sue Meaker Unannounced Inspection 8th November 2005 10:00 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 Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 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. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elmstead Address Elmstead 104 Elmstead Lane Chislehurst Kent BR7 5EL 020 8467 0007 020 8295 3133 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) BUPA Care Homes Limited Mrs Helen Smith Care Home 49 Category(ies) of Dementia (14), Learning disability over 65 years registration, with number of age (1), Old age, not falling within any other of places category (34) Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Service User category LD(E) relates to a named service user. The category to be reviewed if the service user leaves the home. 24th May 2005 Date of last inspection Brief Description of the Service: Elmstead is a care home operated by BUPA, and caters for thirty four elderely frail people and fifteen elderly people with Dementia. The care home is located in Chislehurst, Kent within the London Borough of Bromley. The home is a large three storey detached building situated on a busy thoroughfare in a residential area. There is limited off road parking to the front of the building, and a pleasant secluded garden to the rear of the building with a patio and seating areas. The home offers accommodation in mainly single rooms although there are now only two shared rooms (that are due to be converted to singles as part of an ongoing refurbishment programme). The bedrooms include nine en suite rooms, bedrooms are well decorated and furnished to a high standard; as are the communal areas of the home. Bedrooms, bathrooms and toilets are fitted with locks to ensure privacy; however in the event of an emergency the rooms can be accessed by staff. All communal areas, within the home, are well maintained and provide pleasant seating areas that are are easily accessed by the residents and their visitors; a passenger lift gives residents access to the first floor of the home. Bathrooms and toilets benefit from specialist moving and lifting aids such as hoists and parker baths. Residents have access to a telephone and are able to make calls when they wish; there is also provision for residents to have a telephone in their own room at their own expense. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory unannounced inspection of this home, the previous inspection was undertaken on the 24th May 2005. The inspection took place over a period of four hours, a tour of the premises took place, records were inspected appertaining to the recommendations made in the previous report. A discussion was held with the acting manager of the home relating to the management structure of the home and as to the current position relating the implementation of recommendations made at the previous inspection. Conversations were held with five service users, two visitors and two members of staff. Comments made were of a positive nature, staff were praised for their commitment to the care of the service users. The inspector would like to thank the service users, their relatives, staff and management for their input into this inspection and subsequent report. What the service does well: What has improved since the last inspection? The home is still in the process of an extensive redecoration and refurbishment programme with emphasis placed on creating more single en-suite bedrooms. One of these rooms had been completed to a high standard, the quality of the decoration, furniture and soft furnishings being of good quality. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 6 The repair to the ceiling in the kitchen has now been satisfactorily completed. Recommendations were made in the previous report relating to the pre admission assessment; information from this assessment was not readily available to service users, their relatives or care staff; this issue has now been satisfactorily resolved. Also care plan documentation is to be improved so that service users and/or their relatives can sign to state that they agree with the aims and objectives of the care plan and how they are to be achieved. 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. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 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 Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 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): None EVIDENCE: Standards 1 to 5 were comprehensively assessed in the previous report of the 24th May 2005, and were met. Please note that standard 6 is not applicable to this home. Recommendations made in the previous report, appertaining to standards 3 and 4, have now been addressed and subsequently meet the standards. These recommendations referred to the pre assessment documentation being easily accessible to residents, their representatives and care staff, this issue has now been satisfactorily resolved. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 9 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): 11 Service user’s family and friends are involved (if that is what the service user wants) in planning and dealing with increasing infirmity, terminal illness and death. EVIDENCE: The home has a comprehensive policy and procedure relating to increasing infirmity, terminal illness and death. The home respects the wishes of the service user and their family and friends about this issue; it was evident that discussions relating to this issue are dealt with sensitively and with compassion with all those involved; the care plan states what spiritual needs, rights and functions need to be observed and that the wishes of the service user are adhered to; making sure that the staff will treat them and their family with care, sensitivity and respect. Standards 7,8,9 and 10 were assessed in the previous report of the 24th May 2005 and were met. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 10 A recommendation was made in respect of Standard 7, appertaining to the signature of the service user or relatives on the care plan, this issue has now been addressed and now complies with the standard. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 11 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): None EVIDENCE: All the standards in this section of the report were comprehensively assessed at the previous inspection on the 24th May 2005, and were met. Two recommendations were made in respect of standard 12; these related to a copy of the home’s activity programme, a copy of which has been received by the Commission. An Activities Co-ordinator has been appointed but has not yet taken up the post, this should happen in the new year 2006; the care managers have been implemented some activities for the service users in the interim. The home has implemented an activities weekly checklist and an activities evaluation sheet to ascertain that they are providing activities that the service users would like and enjoy. This situation will be monitored in detail at the next inspection and the Home manager must inform the Commission, in writing, when the Activities Co-ordinator is in post and give details of the activity programme provided for the service users. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 12 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): None EVIDENCE: All the standards in this section of the report were comprehensively addressed in the previous inspection report of the 24th May 2005, and were met. The home had received one complaint since the last inspection, this related to an incorrect invoice being submitted to a service user, the homes’ complaints procedure was implemented and the complaint was resolved to the residents’ satisfaction within a two week timescale; this complaint was not referred to the CSCI. No requirements or recommendations were made in respect of these standards. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 13 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): 21,22 and 23 Service users’ own rooms suit their assessed needs, the home provides suitable lavatories, washing facilities and specialist equipment; therefore meeting the assessed health, personal and social needs of the service user as identified in the individual care plan. EVIDENCE: During a tour of the home, toilets and bathrooms were inspected all of which were well equipped and maintained; there were grab rails and raised toilet seats in the lavatories and parker baths and bath hoist in the bathrooms. The water temperatures were maintained and records kept, the equipment in place was regularly serviced, as evidenced by the service records seen. The home wide corridors fitted with handrails in all to enable service users to move safely around the home even when using wheelchairs and/or zimmer frames. Hoists are provided and well maintained, regular servicing was evidenced by records kept in the home, risk assessments relating to moving and handling were seen on care plans, that identified whether or not service users needed to use the hoists to maintain mobility; it was evident from Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 14 training records seen that staff were trained in the use of the hoist. Pressure relieving equipment is accessed via the District Nurses from a referral by the GP currently there are no service users receiving pressure care. The home is in the process of converting existing double rooms to single occupancy, bedrooms seen, with the permission of the service user, were of optimum size, well decorated and furnished to reflect the service users needs. The home has nine en-suite rooms, with plans to convert more in the future. Standards 19,20,24,25 and 26 were previously assessed at the inspection on the 24th May 2005, and are met. Two recommendations were made in the previous report one relating to the repair of the kitchen ceiling, this work has now been completed satisfactorily; and one relating to the ongoing maintenance, redecoration and refurbishment, the Commission still needs to be kept informed of progress made in these areas. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 15 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): 28 The home ensures that all the service users are in safe hands at all times by making sure that all staff receive appropriate accredited training enabling them to meet the assessed health, personal and social needs of the service users resident in the home. EVIDENCE: All staff are supported and encouraged to undertake accredited training, the home has a comprehensive NVQ training programme in place; currently five staff have completed NVQ 2, with a further six members of staff to commence this training in January 2006. Four members of staff have completed NVQ 3 training and the deputy manager of the home has attained the Registered Managers Award as well as the Joseph Rowntree Award. The home has achieved the minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) by 2005. The acting manager in the home has yet to complete the Registered Managers Award, but does have appropriate care management qualifications; this issue will be further explored in Standard 31. Standards 27,29 and 30 were assessed in detail at the previous inspection on 24th May 2005, and were met. No requirements or recommendations were made in respect of the above standards in the previous report. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 16 Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 37. Although the home has a temporary management structure in place, this needs to be reviewed and formalised, therefore providing the home with more stability. The home has robust policies and procedures in place demonstrating that service users financial interests are safeguarded. Records required by regulation for the protection of service users, and for the effective running of the business are maintained, up to date and accurate ensuring that the service users best interests are maintained at all times. EVIDENCE: Currently the Registered Manager of the home is on long term sick leave, the Commission understands that this situation has now been resolved and that the present acting manager will be permanently assigned to this post. The organisation must apply to the Commission as soon as possible to amend the registration of the home to reflect this new situation. The acting manager Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 18 must also apply to the Commission to become the Registered Manager of the home if this is to be the case; this application must be made as a matter of urgency so that it can be processed as soon as possible. The Commission will also require the newly appointed manager to undertake the Registered Managers Award as soon as possible, and to apprise the commission of a start and completion date. The organisation has a business and financial plan for the home ensuring that the home is financially viable; budgets are allocated and maintained by the home manager and appropriate records are kept. The home has a current in date certificate of insurance complying with standards 34.2 and 34.3. This certificate was seen at the time of the inspection. Service users have access to their records and information held by the home, as well as opportunities to help maintain their personal records if they are able to do so. Records seen were well maintained, up to date and accurate complying with the Data Protection Act 1998. Standards 31,33,35.36 and 38 were assessed in detail at the previous inspection on 24th May 2005, and were met. The accounting and financial procedures of the home now meet the standard a recommendation was made in the previous report relating to this issue. Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 19 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X 3 3 3 3 X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 X 3 X X 3 X Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 20 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 31 Regulation 8 Requirement The Registered Person must ensure that the Commission is informed regarding the any changes to the management structure in the home. Timescale for action 31/01/06 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 Refer to Standard 12 12 Good Practice Recommendations The Registered manager should inform the Commission when the new activities co-ordinator commences duties in the home and give details of days and hours to be worked. The Registered manager should send to the Commission a copy of the new activities programme, incorporating outings and day trips organised for the benefit of the service users. The Registered manager should inform the Commission of any changes to the number of beds available in the home. The Registered manager should keep the Commission informed of all maintenance, redecoration and refurbishment in the home namely the completion date. 3 3 19 19 Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Elmstead DS0000006930.V259522.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!