Inspection on 09/05/07 for Elmstead

This inspection was carried out on 9th May 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

Elmstead 16/05/06

Elmstead 08/11/05

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 09:30 9 & 10th May 2007 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 Elmstead DS0000006930.V335621.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. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmstead Address Elmstead 104 Elmstead Lane Chislehurst Kent BR7 5EL 020 8467 0007 020 8295 3133 marstona@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited 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) ** Post Vacant *** 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.V335621.R01.S.doc Version 5.2 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. 16th May 2006 Date of last inspection Brief Description of the Service: Elmstead is a care home operated by BUPA, and caters for thirty elderly frail people and fourteen 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 to a total of forty-four residents in single rooms. Nine of the bedrooms in the home have en suite facilities while the rest have wash hand basins and access to toilet facilities and bathrooms within the home; bedrooms are well decorated and furnished to a high standard; as are the communal areas of the home. Each of the three floors has two bathrooms and a separate shower room, as well as separate toilet facilities; bathrooms and toilets benefit from specialist moving and lifting aids such as hoists and parker baths. Bedrooms, bathrooms and toilets are fitted with locks to ensure privacy; staff in the event of an emergency can access rooms. All communal areas, within the home, are well maintained and provide pleasant seating areas that are easily accessed by the residents and their visitors; a passenger lift gives residents access to the first and second floors of the home. There are satellites kitchens on each floor, so all meals are served in the individual units; residents are able to choose to dine with other residents or in their own room. Each of the units has a themed communal area. There is a café on the ground floor in which residents and their visitors can sit and enjoy a chat over a cup of tea. The middle floor has a communal lounge that has an organ used for musical interludes for the residents and the top floor has a pub called the “Elmstead Arms”, residents and their visitors have an open invitation to pop in for a game of cards or join in one of the karaoke sessions. Residents from any of the units are encouraged to access these facilities. The home also has a day centre that caters for older people needing day care. The centre is open six days a week and has separate dining and activities facilities and its own staff team. This area is also used for social events such as Christmas and Easter parties. 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.V335621.R01.S.doc Version 5.2 Page 5 Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place over a period of one and a half days. A pre inspection questionnaire was received from the home manager. Four residents’ and four relatives surveys were received. During the inspection time was spent speaking to residents and visitors to the home; there was a discussion with the home manager and her deputy plus other members of the staff team. There was also input from the GP surgery and the district nurse who visit the home on a regular basis; the majority of whom made positive comments about the quality of care at the home. Five care plans, four personnel files, rotas, the menu, the activities programme, training files, business plan, maintenance programme, health and safety, medication and quality assurance documentation were inspected. What the service does well: During a tour of the home it was evident that the staff spoke to the residents respectfully and that they respected their right to choose, their privacy and their independence. Residents confirmed that the staff were easy to talk to and would do anything for them, that they felt comfortable and trusted the staff with all aspects of their personal care and that they were confident that the staff had the necessary skills, competence and experience to care for them appropriately. It is evident that the home provides a good quality of care to the residents; the staff caring and sensitive to the needs of the residents in their care. When speaking to residents it was evident that there was a rapport between them; the residents were treated with respect and their wishes and preferences taken into account. Visitors said that they felt welcome in the home and that any concerns they raised were listened to and resolved quickly this was confirmed by the comments made in the surveys received for example:• My son visited the home and was impressed by the friendly staff and nice atmosphere. • The staff are very helpful and attentive which makes the home a happy place to be. • Since my mother has been a resident she has put on weight and I am sure this is because the food is excellent and the mealtimes appear to be a happy and social part of her day. • I am very impressed with the staff, I have not met one who does not have a smile or a caring word. • Staff have, in my experience, the right skills and experience to look after the residents properly. • Staff have a sense of humour, vitality and happiness; they work as a team. • The home meets the needs of my relative exceptionally well. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 7 • I visit my mother every day; the staff are always ready to discuss any concerns I have and keep me up to date with her progress. The home is maintained, decorated and furnished to a good standard with good communal space including a pub and café areas for the residents and their relatives to enjoy. What has improved since the last inspection? What they could do better: Since the last inspection the full time activities co-ordinator has left and the post has now been split into two providing activities from Monday to Sunday; there is an activities programme that is currently being revised, residents and relatives are being asked for their ideas and what they would like to do and what interests them. However some of the surveys returned felt that there were not enough activities or outings arranged for the residents, one relative said that the staff should be able to spend time with the residents; and another relative said that there should be more organised activities because Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 8 there are not enough and that the staff are left to entertain the residents when they have the time. One relative stated that there was not enough stimulation for the residents in the dementia unit and that there should be activities tailored specifically to the needs of residents with dementia. (A requirement has been made relating to this issue). The rotas looked to reflect the needs of the service users making sure that the number of staff on duty at any time of the day were sufficient in number and that they had completed appropriate training enabling them to meet the assessed needs of the service users in their care. However it would be in the interests of the residents and their relatives to undertake a dependency assessment for the residents in the dementia unit to ascertain their level of need and thereby making sure that there are sufficient staff on duty, at all times, to meet their complex care needs (A requirement and a recommendation have been made relating to this issue). The issue of the Registered Manager of this home is still not resolved satisfactorily; a new manager was appointed seven months ago, she was not registered to the home and is to move to another home within the organisation, leaving the home without a registered manager; it is understood that the post is to be advertised and an appointment made as soon as possible. During the recruitment process the home will be managed by the Operations Manager assisted by the deputy manager, this management structure is still under review and needs to be regularised. The organisation must appoint a permanent manager to the home and subsequently apply to the commission for the appointed manager to be registered and the registration certificate to reflect the new structure. The Registered Manager must also undertake the Registered Managers Award and complete as soon as possible; and notify the Commission of a start date and a completion date. (Two requirements have been made relating to this issue). 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. Elmstead DS0000006930.V335621.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 Elmstead DS0000006930.V335621.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): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives receive comprehensive information about the home so they can make an informed decision as to whether the home can meet their assessed personal, health and social care needs. EVIDENCE: The home has a reviewed and updated Statement of Purpose and Service User Guide, this was completed by the home manager in May 2007 and will be distributed to all the residents and their relatives. The home provides a brochure including a welcoming letter, information about the company, a newsletter, and a copy of the Service User Guide detailing all the services and facilities offered by the home; the Service User Guide is given to each resident Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 11 and is available to relatives. The Statement of Purpose seen complies with schedule 1 of the National Minimum Standards – Care Homes Regulations. Staff survey’s received confirmed that residents and their relatives received enough information about the home before they moved in enabling them to decide if it was the right place for them; one resident said that she visited the home and another stated that her son visited the home and was impressed by the friendly staff and nice atmosphere. The home has a robust pre-admission assessment process; five residents files were seen; two files contained local social services assessments and a preadmission assessment of need undertaken by the home manager. The other three files seen were private referrals; from talking to the home manager it was evident that the prospective resident was visited either in their own home or in hospital and the assessment involved talking to the prospective resident and their relatives and any health professionals involved, the assessment documentation showed that all these parties had contributed to the assessment. Residents and relatives spoken to confirmed that they had been involved in the process and that their wishes and preferences were taken into account when deciding how the staff could meet their personal, health and social care needs. Surveys received evidenced that residents felt that the home could meet their needs and that they received the care and support they needed; one resident said that all the care is very good, another said that the staff are very helpful and attentive; relatives said that the home meets the needs of their relative exceptionally well and another stated that their knowledge of my relatives condition and how her days/nights have been is always spot on; another relative stated that the staff have the right skills and experience to look after the people in their care properly. From looking at the five care files and from information received from the residents and relatives survey’s; residents received a contract specifying the terms and conditions of their residency; this document included details of the role and responsibility of the provider and the rights and obligations of the individual. Please note that Standard 6 is not applicable to this home. Elmstead DS0000006930.V335621.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect the personal, health and social needs of the service user, information is agreed with the service user and their relatives and advocates; enabling staff to deliver care as specified respecting the service users rights relating to choice, dignity and privacy. . EVIDENCE: The organisation has introduced a new care planning system called QUEST, the documentation was developed in house with input from home managers and staff. Elmstead is in the process of changing over to the new system and this process is due to be completed by the end of May 2007. The five care plans seen at the inspection, had the new documentation completed, the system is much improved and more personalised to the individual giving clear Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 13 information relating to the residents’ personal. health and social care needs and how those needs are to be met and what outcomes are to be achieved. It was evident from looking at the plans and discussions with the staff, that the new system gave a comprehensive picture of the resident and their specific care needs and that the staff felt more involved in providing the right level of support and encouragement to the resident, there was also evidence of discussions with the residents and with their relatives. Staff confirmed that they had received training in the new system and had been given extra hours in which to complete the transfer of care plans to the new system; staff members said that it was an opportunity to review and update all information with the residents and their relatives. The care plans were supported by relevant risk assessments that are reviewed on a basis and updated and amended accordingly. The care plans seen included a “map of Life” giving details of the residents past life their likes and dislikes, the jobs they did, their interests and hobbies, information about their family, their pets, holidays and education enabling activities to be tailored to individual tastes and giving the staff subjects for conversations with residents. The surveys received from residents and relatives confirmed that the staff listen and act on what they say; are available when needed, that staff give the care and support that was agreed and expected and that the care service supports residents to live the life they choose. The residents are able to access healthcare services to meet assessed needs; the local GP attends the home twice a week and there is also an emergency call out service. The district nurse was visiting the home at the time of the inspection, she was in the home to renew dressings and to administer insulin injections to diabetic residents; her comments were positive and she said that the care given was of a high standard, that the residents were well cared for and that the staff were skilled and competent to meet the care needs of their residents. The community psychiatric nurse, the occupational therapist, dietician, speech therapist, dentist, audiologist and physiotherapist are all accessed from referrals by the GP, there was evidence in the care plans that residents had been referred to specialist healthcare professionals and appointments were recorded. The optician and podiatrist visit the home on a regular basis. Medication was checked and found to be accurate; there are robust policies and procedures in place a copy of which is in the medication file along with signatures of staff trained to give medication; staff personnel files confirmed that staff receive training in the safe administration of medication; staff spoken to were aware of the policies and procedures and were observed giving medication during the inspection. The MARS sheets were accurately completed and most of the sheets had current photographs of the residents, this issue was discussed at the time of the inspection. The home manager is in discussion with the homes’ pharmacist to change the medication administration system from dosette boxes to blister packs. The clinical room on the first floor was clean and tidy and well ventilated. There is plenty of storage space and the fridge temperatures were being recorded daily. The clinical room on the Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 14 ground floor needs to be re-organised to maximise the use of the space available. During a tour of the home it was evident that the staff spoke to the residents respectfully and that they respected their right to choose, their privacy and their independence. Residents confirmed that the staff were easy to talk to and would do anything for them, that they felt comfortable and trusted the staff with all aspects of their personal care and that they were confident that the staff had the necessary skills, competence and experience to care for them appropriately. The staff are trained to deal discreetly with the affairs of the residents and safeguard the confidentiality of information held about them; residents are aware of the information held about them how it is used and how they can access it thereby maintaining their legal, civic and political rights. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The home endeavours to provide appropriate activities to the residents, supporting and encouraging them to maintain their chosen lifestyle in a residential care home environment. The residents are provided with a nutritious and healthy menu served in congenial surroundings. EVIDENCE: Since the last inspection the full time activities co-ordinator has left and the post has now been split into two providing activities from Monday to Sunday; there is an activities programme that is currently being revised, residents and relatives are being asked for their ideas and what they would like to do and what interests them. However some of the surveys returned felt that there Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 16 were not enough activities or outings arranged for the residents, one relative said that the staff should be able to spend time with the residents; and another relative said that there should be more organised activities because there are not enough and that the staff are left to entertain the residents when they have the time. One relative stated that there was not enough stimulation for the residents in the dementia unit and that there should be activities tailored specifically to the needs of residents with dementia. The home manager is aware that the activity programme of the home needs to be expanded and is looking at appropriate training for the two new members of staff. The home has a pub within the home called the “Elmstead Arms” where residents and their families can experience the atmosphere of a real pub, entertainment such as karaoke, dominoes and reminiscence. There is also a café area where residents can take their visitors for tea and biscuits and for a chat in pleasant surroundings. On speaking to the activities co-ordinator, on duty, it was clear that she had some very good ideas and she was spending her induction period talking to the residents and their families about what type pf activities they would enjoy; she had arranged for a dog training team to come in to give a demonstration called Paws in Motion” in the garden, to show what the dogs could do and to involve the residents in meeting the dogs and their owners. She was also interested in reminiscence training and was hoping to attend a course at the PUMPHOUSE museum in Greenwich. The home manager is keen to involve the residents and their families in completing life histories particularly for the residents in the dementia unit so that activities can be tailored to the hobbies and any interests they had prior to coming into the home. The home does need to arrange more social events and outings to local attractions; the home manager is aware of this shortcoming and will be discussing this issue with the activities co-ordinators, the residents and their families. During the inspection there were opportunities to chat to visitors to the home; generally the comments made about the care and facilities were positive; however there were some concerns voiced about the number of staff on duty particularly at week ends and a comment was made that sometimes staff are too busy to chat to residents; however there were instances during the inspection when it was noted that staff were chatting to residents when giving cups of tea. And during the serving of lunch particularly when feeding the residents. The visitors did say that they felt welcome in the home and were offered refreshments on their arrival; that the management and staff were on hand to discuss any queries or concerns, and that issues were dealt with quickly and sensitively. The residents are supported and encouraged to maintain their links with the local community and to avail themselves of facilities within the vicinity of the home; staff sometimes accompany the more mobile residents to the local shops, the post office, the bank, the library and the chemist all of which are within easy reach of the home. The home is also on a bus route enabling the residents if they wish, to go to the shopping centre, the theatre, restaurants and leisure centres within the London Borough of Bromley. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 17 The residents are able to choose from a balanced, healthy and nutritious menu; meals can either be served in the main dining rooms or in their room. Residents are asked to choose what they would like to eat, if they do not like anything on the menu that day they are offered alternatives by the chef; when a new resident comes into the home the chef with discuss their dietary requirements and their likes and dislikes. The chef spoken to was knowledgeable about special diets such as diabetic, low fat, reducing and gluten free The serving of lunch was observed; the food was well presented, looked appetizing and nutritious in content. Some residents needed help from staff in eating their meal and it was noted that they were being assisted unobtrusively by staff; this was being done in a sensitive manner and the residents, particularly on the dementia unit seemed to appreciate of the help they were being given. Residents on the residential units said that they enjoyed the food and that there was plenty of it and that they could choose alternatives if they wished. The chef manager explained that he varied the menu particularly summer and winter thereby taking advantage of food in season; and that he was aware of healthy eating and the menu seen reflected this concept. The organisation has recently introduced the “nite bite menu”, where residents can order food for the evening, residents choose from a menu displayed in the dining rooms and make their choice and specify the time, sandwiches, hot and cold drinks are some of the things on offer. The kitchen has a Clean Food Award from London Borough of Bromley Environmental Health. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 18 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, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to feel safe and protected in the home due to the organisations complaint and POVA policies and procedures The residents’ legal rights are protected. EVIDENCE: The home has a complaints policy and procedure that complies with the National Minimum Standards; this document forms part of the homes’ Statement of Purpose; and is included in the Service User Guide given to every service user in the home. The complaints policy and procedure is also displayed in all communal areas throughout the home. The home maintains a complaints log; complaints are initially investigated by the home manager and the outcome communicated to the complainant. Relatives surveys stated that they were aware of how to make a complaint, three out of four relatives said that they received appropriate responses when they raised concerns about the standard of care, however one of the surveys stated that the management of the home usually responded appropriately however sometimes they were not completely satisfied with some of the outcomes to concerns raised relating to care and staffing issues. Residents confirmed, when chatted to and from Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 19 completing their surveys that they knew how to complain if they were unhappy or if they had any concerns about anything in the home; they said that they usually approached the care manager of their unit about any concerns they had and said that they were dealt with and resolved quickly. Since the last inspection there have been five complaints; the documentation was looked at during this inspection and the complaints were discussed with the home manager only one of the complaints was partly substantiated. The complaints had been logged, a complaints record form had been completed foe each complaint, and an investigation sheet was completed. All the complaints had been documented correctly and within the timescale specified in the organisations policy and procedure; the outcome of the complaint was sent to the complainant for resolution. No complaints have been referred to the CSCI or been investigated under POVA procedures. The home displays information about advocacy services within the local area and is able to access the service on behalf of residents who do not have any next of kin to manage their affairs. Residents are encouraged and supported to vote in general and local elections either by visiting a local polling stations or applying for a postal vote. The home has a robust policy and procedure relating to the Protection of Vulnerable Adults; in conjunction with the Local Authority Guidelines; both these documents are available to staff and staff also confirmed that they have completed training courses about these issues. Staff interviewed during the inspection showed an understanding of how an allegation of abuse is taken forward using the homes’ policy and procedure and the London Borough of Bromley Guidelines; they were also aware of how to instigate the “Whistle-blowing” policy and procedure. . Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 20 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, 20, 21 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well- maintained safe and comfortable home that encourages and supports their independence by making sure the layout and design of the home is resident friendly. EVIDENCE: Generally the home is in a good state of repair; the home employs a full time maintenance person who is responsible for the day to day routine maintenance of the home; areas in need of redecoration are identified by the maintenance person in discussion with the home manager and the estates manager. The home has a budget for redecoration and refurbishment and there is an annual maintenance plan in place. It was evident from touring the home at this Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 21 inspection, that a lot of work has been put into improving the decoration in service users bedrooms, bathrooms and communal areas; some of the furniture and some carpets have been replaced, the home has a homely, comfortable feel to it; the “pub” area has been well thought out and the decoration in keeping with the theme. The café on the ground floor is now complete the decoration and the furnishings in keeping with the theme; residents said it was a nice place to entertain their family and friends; and it was evident from talking to visitors and staff that the pub and the café were well used. The residents and their visitors have access to the gardens surrounding the home, this area is well kept and provides a good outside space for residents and visitors when the weather is nice. The lunge and dining room areas are decorated and furnished to a good standard and have a homely feel; every effort has been make sure that the residents and their visitors fell comfortable in their surroundings. The home has nine en-suite bedrooms, the rest of the bedrooms share the toilet and bathroom facilities; the facilities seen were in a good state of repair, well equipped with hoists, parker baths and toilets had raised seats and grab rails. Bathrooms and toilets were maintained to a good standard and kept in a clean and hygienic condition. The bedrooms seen in both the residential units and the dementia unit are well decorated and the furniture and soft furnishings were of a good standard; the rooms had been personalised by either the resident or their family and the rooms contained small items of furniture and ornaments, photographs and pictures; many of the residents had their own televisions, music centres and radios. Residents and visitors spoken to said that they were encouraged to bring their personal belongings into the home and said that it helped them to “settle in” and feel more “at home”. During a tour of the home it was evident that the home was clean and tidy, pleasant and hygienic creating a homely environment for the residents and their visitors. The homes’ high standard of cleanliness is the work of a dedicated team of housekeeping staff who maintain the standards expected by the residents. This group of staff is trained to NVQ standard and have all undertaken COSHH training and training in infection control. The residents and relatives surveyed agreed that the home was always fresh and clean. The laundry facilities in the home are good, the laundry is well organised and the residents clothing and the linen used in the home were in a good state of repair; the laundry person spoken to was aware of the homes’ policies and procedures regarding the laundry and confirmed that she had COSHH and infection control training. The washing machines, dryers and ironing equipment were all in working order. The laundry bags used were colour coded and disposable bags were available for infected laundry. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 22 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 using available evidence including a visit to this service. The management of the home endeavours to ensure that staff team are able to meet the personal, health and social needs of the service users; this is achieved by implementing the organisations stringent recruitment and selection policies and procedures and implementing a good induction training programme complemented by additional training to update staffs skills. EVIDENCE: Rotas were looked at to ascertain that there were sufficient staff on duty, with the necessary skills to meet the personal, health and social care needs of the service users; however some relatives have voiced concerns about the number of staff on duty, particularly at the week ends and the number of staff allocated to the dementia unit. . Other residents and relatives surveyed stated that they felt that they always received the care and support they needed, that the staff were always available when needed, that staff listened to and acted on what they said, that the care staff have the right skills and experience to look after people properly and that the home gave the expected and agreed level of care and support to their relative. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 23 The rotas looked to reflect the needs of the service users making sure that the number of staff on duty at any time of the day were sufficient in number and that they had completed appropriate training enabling them to meet the assessed needs of the service users in their care. However it would be in the interests of the residents and their relatives to undertake a dependency assessment for the residents in the dementia unit to ascertain their level of need and thereby making sure that there are sufficient staff on duty, at all times, to meet their complex care needs The organisation has policies and procedures around the recruitment and selection; these policies and procedures incorporate the organisations disciplinary and grievance procedures; staff said they were aware of their employment rights and how to implement these procedures if it became necessary. All staff spoken to confirmed that they had been CRB checked and that they were aware of the POVA register. Four personnel files were looked at and found to comply with schedule 2 of the National Minimum standards – Care Homes Regulations. A number of staff were spoken during the inspection; a recently recruited member of staff confirmed that the recruitment process was thorough and that the questions asked at interview properly reflected the work they were required to undertake; staff also stated that they completed the induction period with a mentor, and that they had mandatory training in moving and handling, health and safety, food hygiene and fire training. All members of staff have a personal training record that is on a regular basis. Staff confirmed that they are kept fully informed about training courses offered by the organisation and are encouraged to put their names forward. These courses include NVQ 2 and 3, understanding dementia, challenging behaviour, medication, health and safety, infection control, nutrition and COSHH. The home has a stable staff team who appear to work together well, supporting and encouraging each other in the work they do, the home has regular staff meetings and team meetings where they are able to voice any concerns they have about the home and the service provided. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 24 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, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The organisation will need to put a temporary management structure in place however this situation needs to be reviewed and formalised. The home has effective and efficient financial, administrative and health and safety systems in place ensuring the stability of the home and safety of the service users, their relatives and staff. EVIDENCE: The issue of the Registered Manager of this home is still not resolved satisfactorily; a new manager was appointed seven months ago, she was not registered to the home and is to move to another home within the Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 25 organisation, leaving the home without a registered manager; it is understood that the post is to be advertised and an appointment made as soon as possible. During the recruitment process the home will be managed by the Operations Manager assisted by the deputy manager, this management structure is still under review and needs to be regularised. The organisation must appoint a permanent manager to the home and subsequently apply to the commission for the appointed manager to be registered and the registration certificate to reflect the new structure. The Registered Manager must also undertake the Registered Managers Award and complete as soon as possible; and notify the Commission of a start date and a completion date. Two requirements have been made relating to this issue. The present management team facilitated the inspection and adequately demonstrated that they had the skills and experience to deliver a good quality service. Service users and relatives confirmed that the management and staff of the home were always ready to listen to any concerns they had and that these concerns were dealt with effectively and efficiently. From records seen it was evident that the home holds regular staff and team meetings; and staff confirmed that they now receive regular supervision and that they have an annual appraisal. The Commission has a copy of the homes’ business and financial plan for the coming year that show that the home is financially viable; budgets are allocated by the organisation and managed by the home manager and appropriate records are kept. The Commission has a copy of the resident/relatives questionnaire sent out by the home; also the management team undertakes monthly regulation 26 inspections of the home and sends a copy to the Commission; these documents form part of the quality assurance processes implemented by the home to monitor the quality of care delivered to the residents. The organisation has recently implemented the Personal Best Initiative as part of its quality assurance process; this initiative is about providing services designed to meet and exceed customer’s needs, choices and expectations; thereby developing an understanding of what individual customers want and how to provide it. The initiative was started in the care homes to help improve services to customers; and also to give greater job satisfaction to staff, this being achieved through the Personal Best Development Plan; staff said that they had commenced the programme and found it rewarding and looked upon it as a way to improve their care practices, to identify areas of strength and weakness enabling them to structure appropriate training; the organisation is to be commended on implementing such an initiative. Health and Safety certificates were inspected and copies taken, these documents complied with relevant current legislation detailed in the Care Homes Regulations – National Minimum Standards. The homes’ administrator follows the organisations policy and procedures relating to the safekeeping of the service users personal allowance; in most instances their relatives have taken responsibility for managing their personal allowance. All personal allowances administered by the home are kept in one account; however individuals are able to access a personal statement of Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 26 monies held, all transaction are recorded on the computer system and receipted. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X 3 3 3 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 3 X X 3 Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 28 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 OP31 Regulation 8 Requirement The Registered Person must ensure that the home has a Registered Manager in post. The Registered Person must ensure that the Appointed Manager undertakes the Registered Managers Award and advise the Commission of the start date and the envisaged completion date. Timescale for action 31/08/07 2. OP31 8 31/08/07 3. OP12 16 (2) (n) 4. OP27 18 (1) (a) The Registered Person must 31/08/07 ensure that the residents are provided with an appropriate programme of activities including social events and outings. The Registered Person must 31/07/07 ensure that there are the required number of skilled and competent staff on duty at all times. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 29 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 OP9 OP27 Good Practice Recommendations The Registered Person should ensure that all the MARS sheets have a current photograph of the resident; unless the resident states otherwise. The Registered Person should ensure that a dependency assessment be undertaken for the residents of the dementia unit. Elmstead DS0000006930.V335621.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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