Inspection on 27/09/05 for Elmstead House

This inspection was carried out on 27th September 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 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 24/02/06

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 Daniel Lim Unannounced Inspection 27th September 2005 09:30 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.V249488.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.V249488.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.V249488.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection: 24 January 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 residents 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 residents 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 residential street and is close to transport and community facilities around Hendon Central Station. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 27 September 2005 and took four hours to complete. The inspector inspected both the main home and April Lodge which is now part of Elmstead. The inspector found that many of the National Minimum Standards assessed had been met and the overall quality of care provided was good. During this inspection, the inspector was accompanied by the home manager, Diane Maddaford. The inspector was able to interview five residents independently of staff. They spoke highly of staff and indicated that they were satisfied with the quality of care provided. The inspector also attempted to interview three other residents, but they were unable to provide a view due to their dementia. Six residents’ case records were examined in detail. These were comprehensive. The premises including bedrooms, communal areas and the gardens were inspected and the maintenance records were examined. Four staff on duty were interviewed on a range of topics associated with their work and a sample of staff records were examined. Minutes of meetings were also examined. What the service does well: What has improved since the last inspection? Improvements had been made in the administration and recording of medication. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 6 The required recruitment procedures had been followed and CRB disclosures had been obtained for staff employed. Care documentation including risk assessments had improved and there was evidence that the care plans had been regularly reviewed. 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.V249488.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 House DS0000010436.V249488.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): 3, 4 The manager and her staff had a good understanding of the needs of residents and were able to ensure that their needs were met. The home had however accommodated a resident who was under the age of 65 years and a requirement is made for the home to stop admitting service users outside it’s category of registration. EVIDENCE: Four residents who were interviewed stated that they were generally satisfied with the services provided and their care needs had been met at the home. Comments made by them included, “staff treat me well”, “well cared for” and “staff respectful to me”. A sample of six residents’ case records which were examined contained up to date plans of care and details of how residents needs had been met. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 9 The inspector observed that residents in the home were clean, appropriately dressed and there was regular interaction between staff and residents. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Residents had been treated with respect and arrangements were in place to ensure that their healthcare, personal, cultural and social needs are attended to. EVIDENCE: Feedback received from the five residents interviewed, indicated that residents’ healthcare needs had been met. Comments made included, “I have seen the doctor” and “my medication had been given promptly”. The sample of six case records examined were up to date and plans of care had been reviewed monthly. Records of medical and healthcare treatment were documented. A record of visits made by the GP had been maintained. Staff interviewed were knowledgeable regarding the care to be provided to residents. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 11 The inspector examined the case records of a resident with diabetes and another with a pressure sore. These were noted to be comprehensive and guidance had been provided to staff on the care of these conditions. The temperatures of the fridge and room where medication was stored had been recorded daily and were satisfactory. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The daily life and routines of residents were well organised and met the cultural and social preferences of residents. Residents were generally happy with the activities organised. Residents indicated that they were generally happy with the meals served. Improvements are however, needed in the kitchen. EVIDENCE: The inspector was provided with a programme of weekly activities for the home. These included special religious and cultural events. Residents interviewed were of the opinion that the home’s activities were appropriate. One of the residents interviewed suggested that more activities be provided and that this should included music and exercise sessions. This was discussed with one of the deputy managers (Anne Belcher). She agreed to look into it. In addition, she informed the inspector that more activities would be organised for residents in the near future. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 13 The inspector was also informed by the managers that the home had organised various outings for residents. This had included a recent outing to Greenwich where residents were said to have enjoyed the boat ride. Residents interviewed stated that they were satisfied with the quality of meals provided. The kitchen was inspected. A record of daily fridge and freezer temperatures had been kept. These were satisfactory. The kitchen was well equipped. The inspector however, noted that there was some debris around the edges of the kitchen (under the work tops). For health reasons, these areas must be kept clean. The inspector was not provided with evidence that one of the kitchen staff had attended food hygiene training. The staff member concerned stated that she had attended the training, but left her certificate at home. The registered person must provide evidence that the kitchen staff identified has attended food hygiene training. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 There was evidence that the residents and their representatives were listened to and protected from abuse and neglect. EVIDENCE: The complaints book was examined and complaints made had been promptly responded to The five residents interviewed stated that they were generally satisfied with the care provided and staff treated them well. Staff records contained evidence that staff had been provided with adult protection training. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 The home was clean and well furnished, therefore providing a suitable environment to live in. Improvements are however, needed in the maintenance of the home. EVIDENCE: The premises were inspected and found to be clean and adequately furnished. The hot water in bedrooms was tested and found to be within the required safe temperature range of no higher than 43 C. The gardens were attractive and seating had been provided. Not all the required maintenance records and safety certificates were seen by the inspector. These included safety inspection certificates for the portable appliances, gas installations, electrical installations and hoists.These must be forwarded to the inspector. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 16 Some areas of the home such as the carpets and doors showed signs of wear and tear and staining. A programme of redecoration is needed to ensure that the premises are pleasant and well maintained. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 17 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 The recruitment process in place ensured that residents’ needs were met by an appropriate group of staff. EVIDENCE: Four staff who were on duty were interviewed on a range of topics associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. Residents who were interviewed stated that staff were respectful and responsive towards them. The agreed staffing levels had been maintained and staff and residents interviewed were of the opinion that this was adequate. There was evidence that staff had been provided with essential training. The staff records examined indicated that the required recruitment procedures (including obtaining satisfactory CRB disclosures) had been followed. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,38 Systems were in place to ensure that the rights and interests of residents were safeguarded. However, improvements are needed in the area of health and safety. EVIDENCE: The fire logbook examined indicated that fire drills and weekly checks of the fire alarm had been carried out. Fire training had been arranged for staff. When questioned, staff were knowledgeable regarding the fire procedures. The inspector however, noted that no fire drills had been organised after dark (dusk). This is required to ensure that staff are aware of the required procedure to follow. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 19 The home had not been inspected by the fire authorities (LFEPA) within the past 18 months. The registered person must therefore request for a fire safety inspection of the premises by the fire authorities (LFEPA)) to be carried out. A copy of the report together with details of any action taken must be forwarded to the inspector. Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X X 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 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 3 3 3 X X X 2 Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 21 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 4, 8 Regulation 23(2)(b) Requirement The registered person must apply for and obtain a variation from The CSCI to permit the home to continue accommodating a resident under the age of 65 years. This requirement is restated and reworded. The previous timescale was 1/2/05 2 4 23(2)(b) The registered person must not admit service users under 65 years of age The registered person must ensure that all areas of the kitchen are kept clean. The registered person must provide evidence that the kitchen staff identified in standard 19 had attended food hygiene training. 01/12/05 The registered person must provide the inspector with a plan Elmstead House DS0000010436.V249488.R01.S.doc Version 5.0 Page 22 Timescale for action 30/11/05 13/11/05 3 15 23(2)(d) 01/11/05 4 19 18 (1) (c) (i) 01/12/05 5 19 23(2)(b) for the home to be redecorated 6 19 23(2) The registered person must arrange for safety inspections to be carried out by a qualified professional on -all the portable electrical appliances -the gas installations and -the electrical installations. - the hoists and assisted baths Evidence that these have been done must be forwarded to the inspector . 7 38 23(4) The registered person must request that an inspection be carried out by the LFEPA. A copy of the report together with details of any action taken must be forwarded to the CSCI. The registered person must arrange for fire drills to be organised at least once every three months. One of these must be carried out after dark. 01/12/05 01/12/05 8 38 23(4) 01/12/05 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.V249488.R01.S.doc Version 5.0 Page 23 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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