Inspection on 24/02/06 for Elmstead House

This inspection was carried out on 24th February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elmstead House 05/06/07

Elmstead House 18/07/06

Elmstead House 27/09/05

Elmstead House 24/01/05

Elmstead House 10/08/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOMES FOR OLDER PEOPLE Elmstead House 171 Park Road Hendon London NW4 3TH Lead Inspector Margaret Flaws Unannounced Inspection 24th February 2006 09:00 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 House DS0000010436.V271265.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 House DS0000010436.V271265.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elmstead House Address 171 Park Road Hendon London NW4 3TH 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) 020 8202 6177 020 8202 4157 Care UK Community Partnerships Limited Ms Diane Maddaford Care Home 50 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number disorder, excluding learning disability or of places dementia (20) Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Elmstead House is a care home registered to provide both nursing and personal care for people with dementia and other mental health problems. The home is part of a scheme originally developed by Barnet Health Authority for the reprovision of patients who were receiving long term care at Napsbury Hospital. The original Elmstead House has now combined with April Lodge (adjoining home) and is now registered as a single home. The home may accommodate a maximum of fifty older adults who are over the age of 65 years. It is owned by a Colchester based company Care UK Community Partnerships Limited. The company has a number of care homes in London. The aims and objectives of the home are To provide a safe and homely environment To offer a stimulating environment To recruit adequate, qualified and experienced staff. Invest in employees To provide care support in a way which encourages self-determination and enable each service user to achieve their best quality of life. To deliver care in a manner which maintains dignity and respect and which recognises service users rights. The home consists of two separate adjoining buildings. The building accommodating service users requiring nursing care is a large single storey building with thirty bedrooms. The manager’s office is at the front of this building. The building accommodating service users requiring personal care is in the adjoining double storey building. It has twenty bedrooms located across both floors. There is a parking area at the front of the home and gardens at the back and sides of the home. The home is situated at the end of a quiet street and is close to transport and community facilities around Hendon Central Station. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 5 Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 2005 as part of the routine schedule of inspections for the home. Both parts of the home were inspected. The Registered Manager, the Manager of April Lodge and other senior staff assisted with the inspection. Eight staff, six service users and three relatives were spoken to. Six service users ’ case records were examined in detail. An examination of other home records, staff records, a demonstration of the new Saturn computer system and a tour of the building completed the inspection. What the service does well: What has improved since the last inspection? The Registered Person has applied for a variation from CSCI to continue to accommodate service users under the age of 65 years. No other service users under the age of 65 years have been admitted. The kitchen has been kept clean and kitchen staff have received food hygiene training. The home has undertaken refurbishment of communal areas. New carpets have been laid and lounges, corridors and some bedrooms have been painted. All safety inspections are up to date. Two fire drills have been carried since the last inspection and one of these was after dark. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 7 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 House DS0000010436.V271265.R01.S.doc Version 5.0 Page 8 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 House DS0000010436.V271265.R01.S.doc Version 5.0 Page 9 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): 3 The Registered Manager and her staff have a good understanding of the needs of service users and were able to ensure that their needs were met, especially the needs of service users who are difficult to place. Service users can be confident that their needs will be fully assessed prior to admission. EVIDENCE: An application for variation for service users under the age of 65 is being processed at present. There are five service users in the home who are under this age. The Registered Manager said that two are currently being assessed to move to another home and three will remain at the home. The practice of admitting people under 65 has been reviewed and discontinued. Six care plans were checked. All had evidence of thorough assessment of the service users’ needs prior to moving into the home and their care was regularly reviewed by placing authorities. Assessments for the home are done by the Registered Manager and Deputy Manager. Service users spoken said that that their needs had been assessed. Currently there are three respite beds in the Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 10 home. The Registered Manager described how the home specialises in taking people whom other homes have had difficulty caring for or whose placements had broken down. There has been one new admission since the last inspection. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Service users are treated with respect and arrangements were in place to ensure that their healthcare needs are outlined in sound care plans and met by staff who understand them. EVIDENCE: Six case records were examined in paper and computer formats. These were up to date and care plans were reviewed monthly. There are also comprehensive night care plans. The home has moved to a new system (Saturn) of computerised records. The Registered Manager and Deputy Manager showed these systems to the inspector. Staff have been trained in its use and daily notes are now kept online. There are some dual systems operating in paper form while records are transferred. The inspector looked at daily notes online, care plans and other records. All were of a good standard. Records of medical and healthcare treatment were documented. A record of visits made by the GP had been maintained. There are very thorough mental health risk assessments used in the home and these are updated with the service users’ changing needs. Staff spoken to were knowledgeable about the care to be provided to service users and passionate about the quality of care they wanted to provide. Service Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 12 users said that the staff treated them respectfully and protected their privacy. Staff were observed interacting respectfully and kindly with the service users. Feedback received from the relatives spoken to was positive and indicated that service users ’ healthcare and other needs had been met. Comments included, “it was so heartwarming to see how staff treat my dad as an individual, not just as a sick person. They treat him with great tenderness”, and “ they work from the heart, nothing is too much to ask”. There were no service users with pressure sores in the nursing home. The home has regular contact with tissue viability nurse and the Registered Manager said that several new pressure care mattresses had recently been bought. Regular minuted staff meetings are held and the minutes indicated that of these meetings is on improving the quality of care. The Falls and Restraints Policy has been updated after the home noted an increase in the number of falls in the nursing home. The home has procedure for the use of cot sides, with signed approval forms from relatives or service users. The managers said that the home has a very good relationship with the local CPN teams and hospital based psychiatry services. The temperatures of the fridge and room where medication was stored had been recorded daily and were satisfactory. MAR sheets were sampled and the medication arrangements inspected in the nursing home. These were in good order. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 13 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): 13, 14, 15 Service users can maintain a good standard of contact with family and friends and exercise control over the lives. They indicated that they were generally satisfied with the food. EVIDENCE: Activities were not fully inspected on this occasion. The home employs an Activities Coordinator for thirty hours per week. Service users spoken to were satisfied with the home’s activities. A birthday party was due to commence in April Lodge at the time of inspection. Relatives and service users said that family contact is well supported by the home and that visitors can come at any time. Service users spoken to stated that they were generally satisfied with the quality of meals provided and could exercise choice as to what they wished to eat and also in how they spent their time. One comment received was that there was a high proportion of tinned vegetables served and the Registered Manager said that this would be checked. The home receives deliveries of fresh fruit and vegetables every two days - they were in good supply in the kitchen, and menus are formally changed every six months and operate on a four week cycle. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 14 The kitchen was inspected. A record of daily fridge and freezer temperatures had been kept and were within range. The kitchen was well equipped and clean. The chef said that kitchen staff deep clean the kitchen monthly. Training records showed that all kitchen staff have attended food hygiene training. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 15 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 Service users and their representatives can be confident that they will listened to and protected from abuse and neglect. EVIDENCE: The complaints records were examined. Complaints made had been promptly responded to and investigated. A recent adult protection allegation has been satisfactorily resolved. Staff records were checked and contained evidence that staff had been provided with adult protection training. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26 The home was clean and well furnished and recent redecoration has improved the environment. Minor improvements are needed in bathroom maintenance. EVIDENCE: The premises of Elmstead and April Lodge were inspected and found to be clean, comfortable and well furnished. Bedrooms were adequate and generally personalised by service users as they preferred. A programme of refurbishment and redecoration is underway in the home. The floors in April Lodge have replaced by an attractive wood look non-slip flooring that the Deputy Manager said is also ideal for the home because it doesn’t stain easily and is fire proof. Communal areas (lounges and corridors) and some bedrooms have been repainted, along with some bedrooms. New carpets have been laid. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 17 A shower area in the nursing unit had a drain that needed replacing, along with a shower chair. A toilet seat in this unit was also broker. Requirements are given for these. The home has a fundraising committee and the Registered Manager said that they have raised fund to build a ‘snooze room’ for service users with dementia. The room would provide a comforting sensory experience for these service users. Health and safety certificates were inspected and were in order. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Staffing levels have increased to ensure that service users’ needs are well met. Service users are protected by the home’s recruitment process and from the home’s commitment to training its staff well. EVIDENCE: The Registered Manager described improvements to the staffing structure. An additional staff member has been placed on duty on the afternoons in the nursing unit after an increase in the number of falls was noted. Two service users are also receiving one to one care and support funded by the local PCT (one for palliative care; one for challenging behaviour). The Registered Manager said that the home will regularly add on another member of staff to either unit if service users’ needs increase. The home’s training programme is particularly rigorous. The Registered Manager said that they regretted the loss of a dedicated trainer in the home but will now focus on putting their own staff through Train the Trainer courses. Only five staff out of twenty two have yet to complete an NVQ qualification and the majority hold NVQ3. Some staff have completed a 24 week course in dementia care and all staff have received adult protection and fire training. The home also provides placements for student nurses and for general nursing staff to convert to RMN qualifications. Several overseas trained nurses have also been through an adaptation programme at the home. There was evidence that staff had been provided with mandatory training. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 19 Two new staff have employed since the last inspection and their records were examined. They had all required pre-employment checks in place (including satisfactory CRB disclosures). Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 20 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, 33, 36, 38 The home’s quality assurance process provides a way for the home to receive and act on feedback. Staff supervision is in place to monitor staff performance and protect the service users but improvements are required. A fire safety inspection is still outstanding. EVIDENCE: The Registered Manager said that a recent survey had been sent out to relatives. There was evidence from those surveys returned that relatives generally view the home positively and are happy with the quality of care provided. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 21 Supervision records were inspected. The regularity of supervision has lapsed in the last year and the Registered Manager said that this was partly because of the intense focus on training. It also became clear from the discussion that only a small number of managers provide supervision and that this is too much on top of their current workload. The home is required to ensure that supervision is provided no less than six times per year and to provide supervision skills training to senior staff who could take on this responsibility. The fire logbook examined indicated that fire drills and weekly checks of the fire alarm had been carried out. Staff have received fire training. The home has still not been inspected by the fire authorities (LFEPA) within the past 23 months. The Registered Manager has requested this imspection but said she will follow up again. The reuqirement is restated. Accident and incidient records were inspected and were in order. In April Lodge, all the service users smoke and were observed making good use of the smoking lounge. As a health and safety precaution, after consultation with the service users, the Deputy Manager reported that the service users give their lighters and cigarettes to the staff at night. Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X 2 X 2 Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP21 Regulation 23(2) Requirement The Registered Person must ensure that a shower drain is repaired and a shower chair replaced on the nursing unit. The Registered Person must ensure that a toilet seat is replaced on the nursing unit. The Registered Person must ensure that all staff receive supervision at least six times per year. The Registered Person must ensure that some senior staff are trained to provide supervision to other staff. The Registered Person must request that an inspection be carried out by the LFEPA. A copy of the report together with the details of any action taken must be forwarded to the CSCI. Timescale for action 30/04/06 2 3 OP21 OP36 23(2) 18(1) 30/04/06 30/04/06 4 OP36 18(1) 30/05/06 5 OP38 23(8) 30/06/06 Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elmstead House DS0000010436.V271265.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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