Inspection on 29/09/05 for Elmwood Nursing Home

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Elmwood Nursing Home 07/03/07

Elmwood Nursing Home 13/01/06

Elmwood Nursing Home 16/12/04

Elmwood Nursing Home 16/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Elmwood Nursing Home 3 Wetherby Road Leeds Yorkshire LS8 2JU Lead Inspector Catherine Paling Unannounced Inspection 29th 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 Elmwood Nursing Home DS0000001339.V254346.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.V254346.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.V254346.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16 December 2004 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 65years. 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.V254346.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 first 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 16 December 2004. This was an unannounced inspection carried out by two inspectors who were at the home from 09.30 until 17.15. The main purpose of this inspection was to make sure that the home provides a good standard of care for the service users 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; observing working practices and talking to staff, service users, relatives and to the manager. What the service does well: What has improved since the last inspection? The activity provision at the home has greatly improved recently with the appointment of a new activities organiser. This member of staff has clear commitment and enthusiasm for the role and has established a range of activities for those who like group activities as well as those who prefer more individual pursuits. He is an asset to the home. Elmwood Nursing Home DS0000001339.V254346.R01.S.doc Version 5.0 Page 6 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.V254346.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.V254346.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): EVIDENCE: None of these standards were assessed at this inspection. Elmwood Nursing Home DS0000001339.V254346.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 10. The information within records does not ensure that the physical and healthcare needs of service users are being met, placing the service users at potential risk. EVIDENCE: The case records of three residents were examined; one had only been at the home for a few weeks. The care plans did not provide staff with full and detailed instructions about how to meet the health, personal and social care needs of the residents. For one resident there was a client profile providing an overview and an unsigned and undated ‘Initial assessment’. Neither of these documents provided any detail of care. The purpose of the ‘24hour life plan’ was discussed with the manager. It appeared to provide information about how the resident spends their day but did not necessarily reflect current needs. It was felt that there was a risk that staff would make reference to this rather than care plans as a quick guide to needs. This could result in changes being overlooked. There was a range of care plans but little detailed or specific information about care needs. For example, a plan to meet personal hygiene needs stated ‘needs to be clean and tidy’ and ‘give a bath at least once a week’ with no further Elmwood Nursing Home DS0000001339.V254346.R01.S.doc Version 5.0 Page 10 information about when the resident preferred to have a bath, how many staff were needed or what equipment might be required. Nutritional needs were not addressed in sufficient detailed for a resident who was described as having a poor appetite. For example, ‘promote a well balance diet daily’ without any further detail of how this might be done. A monthly nutritional assessment was carried out which included ‘yes/no’ responses to question as such as ‘poor appetite?’ but this did not actually assess the nutritional risk. Other instructions seen on care plans about nutritional needs included ‘requires full intervention to maintain an adequate diet’ without any guidance as to what intervention was needed. Although a food diary was being used it had not always been completed and the fluid intake was not enough. There was a range of risk assessments carried out including one for the risk of falls, manual handling and the risk of developing skin damage. Turn charts were being used for one resident. Some were not named or dated and one chart had not been completed between 10.00 and 21.00. Where risk had been identified this did not always result in a clear plan of how the risk would be managed. Bed safety rails were in use for one resident without a risk assessment having been carried out. Specific and detailed information was seen in two night care plans, which include information about the lighting levels preferred at night and how late a particular resident liked to watch the television. Daily records were kept and contained information, which should have been included on care plans or should have generated a specific care plan to address that particular issue. For example, daily records for one resident indicated some skin damage and had not resulted in update of the care plan. There was evidence that the daughter of one resident had been closely consulted. However in the case of a recently admitted resident although the daughter had provided written care guidance, this had not been used in the care plans. There was evidence of the involvement of other healthcare professionals although for one resident it was not clear whether chiropody had been arranged even though contact details had been provided by the daughter. Observation and discussion indicated that staff treated the residents with respect. Requirements have been made. Elmwood Nursing Home DS0000001339.V254346.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): 12, 13, and 14. Residents are encouraged to participate in social and leisure activities. Residents exercise choice in their daily lives and they are supported in maintaining contact with family and friends. EVIDENCE: The activities organiser has only been in post for a few weeks. It was evident from observation and from discussion with him that he has a great deal of enthusiasm and commitment for his role. At the time of our arrival he was initiating a discussion with residents on current affairs from a daily newspaper. He said that some service users were knitting in their bedrooms. The mobile library arrived and several books were organised for a specific resident who reads several books in a fortnight. The organiser showed us many paintings done by residents; some had not painted for many years. In the afternoon he facilitated reminiscence with the residents. Plans were well under way for Christmas celebrations. Records of social interests and needs were detailed. There was evidence of a commitment to ensuring residents could exercise choice in how they spend their day. Family and friends are welcomed at the home at any time. Elmwood Nursing Home DS0000001339.V254346.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): 16. The home has a detailed complaints procedure and complaints are dealt with appropriately. EVIDENCE: There is a complaints procedure available to all residents and it is displayed at the home. The manager keeps a log of all complaints and compliments received. The log includes records of how complaints have been dealt with. Monthly returns are made to head office about the number of complaints received. Elmwood Nursing Home DS0000001339.V254346.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): 19, 20, 23 and 24. The home offers a safe and well-maintained environment for residents. EVIDENCE: There is a planned programme for the ongoing refurbishment of the home. Four bedrooms are redecorated each year and a shower has been refurbished since the last inspection. The communal areas are comfortable and reasonably spacious with a small separate lounge for smokers. There is an attractive outside seating area overlooking the landscaped gardens, which is very well used by the residents. Overall the gardens are accessible although one resident had raised a concern about the difficulty of getting his wheelchair over the lip at the front door without help. The manager had agreed to try to find a solution. Bedrooms were spacious and well furnished with many residents surrounded by their personal items. Elmwood Nursing Home DS0000001339.V254346.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): 27, 28, 29 and 30. The numbers and skill mix of staff were sufficient to meet the needs of the residents. Residents are protected by the staff recruitment procedures. Staff are trained and competent to do their jobs. EVIDENCE: The duty rotas indicated that there were sufficient staff on duty throughout the twenty four hour period. Care staff were well supported by a well established and stable team of domestic staff, maintenance and administrative staff and there is also an activities organiser. The manager has some supernumerary time for her managerial responsibilities, which is indicated on the duty rota. The training programme for care staff to achieve National Vocational Training (NVQ) in care at level 2 is well established and the assessor was working with care staff at the home at the time of the visit. The manager is confident that the minimum ratio of 50 trained members of care staff will be achieved by the end of 2005. The manager advised that NVQ level 3 was not yet available to care staff as the priority has been to facilitate NVQ level 2. As well as NVQ training, further training was made available to staff to make sure that they have the skills necessary to properly care for the residents. This includes a distance learning package in nutrition, which all staff are expected to complete, as well as such things as wound care. Elmwood Nursing Home DS0000001339.V254346.R01.S.doc Version 5.0 Page 15 The manager has developed individual training files and also holds information centrally so she can make sure that all staff have completed mandatory training. The personal files of two recently employed staff indicated that all the required checks were being carried out for staff before they are employed at the home. Proposals have been received from the provider to review the skill mix of staff in the light of care staff being trained to NVQ level two. In order to make sure that the nursing staff are adequately supported senior care staff should be trained to NVQ level 3. Issues identified at this inspection with regard to the record keeping suggest that there continues to be a need for a second nurse on the early shift to support the manager in addressing the shortfalls. Elmwood Nursing Home DS0000001339.V254346.R01.S.doc Version 5.0 Page 16 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 and 38. The home is well managed. The interests of the residents are seen as very important to the manager and the staff. The absence of recent fire training for staff could compromise resident safety. EVIDENCE: The registered manager has been at the home for two years and has completed an NVQ in management at level 4. She is an experienced enthusiastic nurse and provides clear leadership to the staff at the home. The manager has an open approach to her role. She has developed her skills in managing effective meetings through her learning during the NVQ. This is evidenced in the open and informative minutes of the meetings held with relatives and residents and those held with the home staff. Elmwood Nursing Home DS0000001339.V254346.R01.S.doc Version 5.0 Page 17 The manager needs to inform the CSCI in writing of her change of name so that the certificate can be issued with her correct name. It was clear from her response to shortfalls identified during the inspection that the manager has a commitment to running the home in the best interests of the residents. Training information indicated that fire training was overdue for some staff. The manager is the accredited fire trainer there were plans to address this for all staff. In the meantime regular weekly fire drills were being held to make sure that staff know what to do in the event of a fire. A requirement has been made. Elmwood Nursing Home DS0000001339.V254346.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 3 x x 3 3 x x STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x x x 2 Elmwood Nursing Home DS0000001339.V254346.R01.S.doc Version 5.0 Page 19 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. The nutritional risk assessments must be revised for all service users, in the light of findings during the inspection, to ensure accuracy and relevance. Specific training in the completion of the nutritional risk assessments must be provided for all staff. The provider must make sure that arrangements are in place for residents to receive treatment from other healthcare professionals. The registered provider must DS0000001339.V254346.R01.S.doc Timescale for action 01/02/06 2 OP8 12(1)(a) 01/02/06 13(1)(b) 3 OP28 18 31/12/05 Page 20 Elmwood Nursing Home Version 5.0 4 OP38 23(4)(d) make sure that the minimum ratio of 50 trained members of care staff is achieved by 2005. The provider must make sure that all staff have received fire training including the night staff. 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elmwood Nursing Home DS0000001339.V254346.R01.S.doc Version 5.0 Page 21 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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