CARE HOMES FOR OLDER PEOPLE
Elmwood Nursing Home 3 Wetherby Road Leeds Yorkshire LS8 2JU Lead Inspector
Catherine Paling Unannounced Inspection 13th January 2006 09:10 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 Elmwood Nursing Home DS0000001339.V273170.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. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Elmwood Nursing Home Address 3 Wetherby Road Leeds Yorkshire LS8 2JU 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) 0113 2323501/2 0113 2733137 BUPA Care Homes (GL) Ltd Ms Sarah-Jayne Isobella Pedel Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 29th September 2005 Brief Description of the Service: Elmwood Nursing home is situated in the suburb of Oakwood in north Leeds. It is in a quiet setting but is situated close to local amenities on the northern end of Roundhay Road. It is on bus routes to the city centre, other parts of Leeds and local towns. The home is also close to Roundhay Park. Elmwood is a purpose built home with accommodation provided over three floors. Personal care with nursing is provided for up to 36 residents over the age of 65 years. There are 32 bedrooms, four of which are shared, all with ensuite toilets. The communal lounges and dining room are on the ground floor. Smokers use the small lounge. There are attractive gardens that are accessible and well used by the residents. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on 29 September 2005. This was an unannounced inspection carried out by one inspector who was at the home from 09.10 until 14.15. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care for the residents and to assess progress on meeting any requirements or recommendations made at the last visit. The methods used at this inspection included looking at care records and other documents; talking to residents and staff as well as the manager and general manager. What the service does well: What has improved since the last inspection?
Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 6 The manager and the staff have worked hard since the last inspection to develop and improve the standard of recording of care needs. Although there remains a great deal of work to do the manager was able to demonstrate the standard she is aiming for. There is a clear commitment to the improvement of these records to make sure that all care needs are clearly documented. The home is one of three situated in the immediate area. Since the previous inspection the managers of the three homes, with the support of the general manager who oversees all three homes, have developed an effective support system for each other. This enables them to share good practice for the benefit of the residents and also to reflect and learn from each other’s experiences. 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. Elmwood Nursing Home DS0000001339.V273170.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 Elmwood Nursing Home DS0000001339.V273170.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. (Standard 6 is not applicable). All residents have their needs thoroughly assessed prior to admission to the home so that they can be assured that their needs can be met. EVIDENCE: Good personal detail was seen in the pre-admission assessment looked at, which follows the activities of daily living. There is a revised format that includes a number of prompts to be sure that all areas of need are explored before admission. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. The information within records does not always ensure that the physical needs of service users are being met, placing the service users at potential risk. Healthcare needs are met and there are safe practices in place with regard to the administration of medicines. EVIDENCE: The manager and her staff are working hard to develop the care records to make sure that they accurately reflect individual care needs. The nursing staff have received training in documentation. Care plan audits are being carried out and are clearly identifying any shortfalls in the standard of recording. The standard being aimed for was demonstrated in one set of records which contained detailed information about the needs of the resident for example, what time she likes to rise and how she spent her day. The nutritional assessment had been carried out and was regularly reviewed. The resulting nutritional care plan was well detailed and contained specific instructions for staff. Personal hygiene needs were also detailed providing information about what the resident was able to do and exactly what help and support was
Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 10 needed from staff. The night care plan was not quite as detailed. The manager had already identified this and was working with night staff. A range of risk assessments were carried out and regularly reviewed. The falls risk assessment format was not being fully utilised. It was recommended that where comments to a particular response were invited, these should be made to make sure that all pertinent detail is recorded. For example, if it is recorded that a resident does not always cooperate during a procedure details should be noted to assist staff. Detailed records were seen of other healthcare professionals visits, for example, the GP and the chiropodist. Clear photographs of residents were held in both the care records and on the medicine administration records (MAR) to assist in identification. There were some omissions on the MAR sheets and the reason was not always clear. There is a signatory list of those staff involved in medicine administration but this was out of date and should be renewed. There was a list of homely remedies signed by one GP. It was recommended that this list should be revise and shared with all the GPs for their agreement. Regular audit of medication administration is carried out. Revised medication procedures have recently been produced. A recommendation and requirement have been made. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15. The residents are provided with a nutritious and balanced diet in pleasant surroundings. EVIDENCE: There is a four-week seasonal menu in place offering a varied choice for the residents. In addition to the menu alternatives are always available and individual likes and dislikes are catered for. The cook has been at the home for a number of years and knows all the residents. There is home baking and residents were offered homemade cake with their afternoon cup of tea. The manager has had regular contact with the dietition in the past and now contacts them only when necessary. Elmwood also provides the catering service for the sister home nearby. The vacancy for a chef manager has been advertised with a good response and interviews are to be held in the near future. Families are welcome to join relatives for lunch and several families were able to join their relatives for Christmas dinner. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Residents are protected from abuse with staff having an increasing awareness of adult protection. EVIDENCE: There are established corporate adult protection procedures at the home. In addition the manager is familiar with the local authority adult protection procedures. The manager has dealt with a recent difficult situation well and has completed a thorough investigation. The CSCI has been kept informed throughout. The manager and a senior member of the nursing staff are to attend training in adult protection later in the year. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26. The home is clean pleasant and hygienic. EVIDENCE: The areas of the home visited were clean. The laundry was clean, tidy and well organised with a range of equipment all of which was in working order. Elmwood provides a full laundry service for its nearby sister home. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: These standard were assessed at the previous inspection. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 15 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): 33, 35 and 38. The home is well managed and the best interests of the residents are safeguarded at all times. EVIDENCE: There is a well-established system of ongoing audit at the home to assist the manager in ensuring that the service to residents is safe and consistent. This includes audit of the housekeeping services; pressure area care; complaints and compliments and also of the maintenance function. In addition to this satisfaction surveys have just been completed and will be published in the near future. The manager works hard at making sure that there are effective communications with residents and their families. She is proactive in providing a little extra support for those families who need it by making sure that she
Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 16 makes contact with them on a regular basis. The manager has recently set up email contact with one family member who lives overseas. There is a strong ethos at the home of safeguarding the interests of the residents and staff are very knowledgeable about individual needs. The manager holds regular meetings with residents and their families and notes of these meetings indicate her openness about any issues raised. Regular meetings are also conducted with all designations of staff. The home has a policy of not handling resident finances or personal allowances. All residents have individual accounts and are provided with regular statements and relatives or their families are invoiced with any additional charges such as chiropody or hairdressing. Clear records are kept of any transactions. All staff have received health and safety training and there is a health and safety group which meets regularly to formally discuss any particular issues. Any accidents occurring at the home are monitored on a regular basis. The maintenance man carries out risk assessment of the building. There are clear records of the checks he undertakes and when. Mandatory training in, for example, fire safety and manual handling is provided for all staff and is up to date. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 17 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 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 15 Requirement Care plans must set out in detail the action which needs to be taken by the nursing and care staff to make sure that all aspects of the health, personal and social care needs of the service user are met. Care plans must be drawn up with the involvement of the service user and agreed and signed by the service user whenever capable and/or their representative. 3. OP28 18 The registered provider must make sure that the minimum ratio of 50 trained members of care staff is achieved. (timescale of 31/12/05 not met) 03/04/06 Timescale for action 05/06/06 Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 19 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. Refer to Standard OP9 Good Practice Recommendations The signatory list should be reviewed to make sure it is up to date and rewritten. The list of homely remedies should be reviewed with the pharmacist and GPs. There should be evidence of the agreement to this list by all the GPs who serve the home. Elmwood Nursing Home DS0000001339.V273170.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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