Inspection on 07/03/07 for Elmwood Nursing Home

This inspection was carried out on 7th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elmwood Nursing Home 13/01/06

Elmwood Nursing Home 29/09/05

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 Key Unannounced Inspection 7th March 2007 09:25 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.V327982.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 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 www.bupa.co.uk BUPA Care Homes (GL) Ltd *** Post Vacant *** Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 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. Information about the service and facilities is available in the form of a statement of purpose and service user guide as well as a home brochure. The current charges range from £580 to £750 per week. Additional charges are made for chiropody, hairdressing, aromatherapy and newspapers and toiletries. This information was included in the pre-inspection questionnaire completed by the provider in February 2007. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way care services are inspected. They are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes and copies of past inspection reports are available on our website – www.csci.org.uk Information about the home is gathered from a variety of sources, one being a site visit. Additional site visits may be made that will concentrate on specific areas such as health care or nutrition called random inspections. One inspector carried out this inspection on 7th March 2007 and was at the home from 09.25 until 17.15. The purpose of this inspection was to assess all the key standards (the key standards are identified in the main body of the report); to assess progress in meeting any requirements made following the previous inspection and to assess how the needs of people living in the home are being met. The methods used at the inspection included looking at care records, talking to residents, observing care practices in the home, talking to staff and management, looking at the environment and looking at other paperwork including staff records. The home provided some information to the CSCI in advance of the inspection. Comment cards were left at the home for residents and their relatives. Survey cards were sent out in advance of the visit to General Practitioners and other visiting healthcare professionals. Following the inspection visit a number of comment cards were received from relatives/visitors and also from residents. The majority of the residents comment cards had been completed with the help of a member of staff; the responses were positive about care and life at the home. Comment cards received from relatives/visitors indicated an overall satisfaction with the care at the home. What the service does well: Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 6 The home is well positioned for access to local amenities and the grounds provide an attractive outlook. The home is well maintained and comfortable. Staff are very welcoming and professional in their manner with a good rapport seen with the residents. One resident said ‘the staff are delightful and friendly’. The new manager has provided continuity to the staff and residents. She provides clear leadership at the home and demonstrates commitment to running the home in the best interests of the residents. The audit systems at the home help the manager to make sure that services and facilities at the home are maintained at a good level. There is a commitment to making sure that staff are properly trained and can effectively care for the residents. This includes National Vocational Qualifications (NVQ) for care staff. The activities organiser is enthusiastic and activity provision continues to develop and addresses individual abilities. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 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.V327982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. (Standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is sufficient information available for current and prospective residents to help them decide about moving into the home. All residents have their needs assessed prior to admission to the home so that they can be assured that they will be looked after properly. EVIDENCE: There is information available for current and prospective residents in the form of a statement of purpose and service user guide. There is also a home brochure that is currently being revised together with all the other information to reflect the change in management arrangements and to make sure that the information included is accurate and up to date. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 9 Detailed pre-admission assessment information was seen in individual records about individual care needs. Information had also been obtained from other agencies involved in the placement for example social services. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Staff respect the privacy and dignity of residents. Healthcare needs are met and there are safe practices in place with regard to the administration of medicines. EVIDENCE: The records of four residents were looked at including a resident who had been at the home for some time as well as more recently admitted residents. A 24 hour life plan had been completed for some residents and included good specific detail about how the individual liked to spend their day. Some of these could have been improved by the addition of more information. For example, Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 11 one life plan made no mention of the resident’s partner who was also living at the home and was central to their wellbeing and also contributed to care. Care plans contained some good instructions and guidance on the intervention needed from staff and strengths and weaknesses had been identified. However in the case of one resident with dementia care plans did not always demonstrate an understanding of the effect of the illness on their abilities. There were care plans for the nighttimes but these did not always include preferred bedtimes and rising times. There were no psychological or end of life plans. The manager expressed an interest in developing this area. There was good and detailed evaluation of care plans that demonstrated a full review is carried out. A range of risk assessments are carried out for all residents for example, the risk of falls, and skin damage. In one case no risk of skin damage had been identified but a care plan had been developed. Information within records should be relevant and up to date. In another case a resident who was at some nutritional risk had no risk assessment or care plan in place. Daily records were kept. There were some gaps on the recording sheets, these should not occur and should be struck out when they do. There is a commitment from the manager to improve the records and new documentation is to be introduced by the provider with the intention of addressing any shortfalls in recording. All staff involved in the administration of medication have had training and update in drug administration. Regular audit of the systems is carried out as part of ongoing monitoring. Clear photographs of residents were held in both the care records and on the medicine administration records (MAR) to assist in identification. A good rapport was seen between residents and the staff. Staff treated the residents with respect and one said that ‘I consider that I am looked after very well’. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. The residents are provided with a nutritious and balanced diet in pleasant surroundings. EVIDENCE: The activities organiser has been at the home for over a year and it was clear that he has a great deal of enthusiasm and commitment for his role. At the time of the visit he was initiating the regular morning discussion with residents on current affairs from a daily newspaper. This was a lively debate with those residents unable to contribute seeming to enjoy the chat. He has established a regular programme of activities involving residents, for example one resident regularly acts as ‘bingo caller’ in the regular weekly game enjoyed by a number of the residents. Records of social interests and needs were detailed. There was evidence of a commitment to ensuring residents could exercise choice in how they spend Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 13 their day. Those residents who are able to go out safely alone or with family, do so. The manager is keen that those needing to be accompanied are also given the chance to visit the local shops. A monthly programme of events is produced in individual copies and circulated to residents. There is a plan underway to have an ‘open house’ for afternoon tea in April inviting elderly neighbours to spend the afternoon at the home and enjoy games and entertainment. This is part of an initiative to raise money for Parkinson Awareness week. The lunchtime meal was observed and seemed to be well managed with residents being enable to eat at their own pace. There has been a review of the meal service and there is now a night time snack menu available for residents. The food looked and smelt appetising. There were mixed views about the food. Some residents were satisfied, some said that the food delivered to their rooms was often cold and others said it often looked and tasted the same. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a detailed complaints procedure and complaints are dealt with appropriately. Residents are protected from abuse with staff having an increasing awareness of adult protection. EVIDENCE: A log is kept of all complaints and compliments received and monthly returns are made to head office. The log includes records of how complaints have been dealt with and indicated that complaints are taken seriously and dealt with appropriately. One comment card indicated that a problem with the hot water had been dealt with promptly. Another concern had been raised about the fees and this had been referred to a director of the company. Residents spoken with also said that they were confident that any concerns they raised would be listened to and dealt with. There are established corporate adult protection procedures at the home. Staff have also received training from the local authority adult protection unit. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 15 Since the last inspection some allegations concerning adult protection issues have been received at the home. These have all been properly dealt with, informing and involving other agencies as needed. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well maintained environment. Not all staff had an understanding of infection control putting residents at potential risk of cross infection EVIDENCE: The areas of the home visited were clean. Bedrooms are furnished to a high standard and many residents have brought their own items in to personalise their rooms. There is an ongoing programme of redecoration of bedrooms. The communal areas are situated on the ground floor and are comfortable and reasonably spacious with a small separate lounge for smokers. There is an attractive outside seating area overlooking the gardens, which is very well used by the residents in the good weather. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 17 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. The communal sanitary facilities include bathrooms and assisted shower rooms. Some of the ancillary staff spoken with did not have an understanding of infection control and records indicated that they had not had training. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The 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 enough staff to meet the needs of the residents at the home. The nurses and the care staff were well supported by a well established and stable ancillary staff team that includes domestic staff, maintenance and administrative staff as well as an activities organiser. Although the manager has supernumerary time for her managerial responsibilities this was not shown on the duty rota. The numbers of care staff who have achieved a National Vocational Qualification (NVQ) in care at level two has exceeded the standard of 50 and is currently in the region of 60 with more carers partway through course. Staff are well supported and given numerous opportunities for training to make sure that they are able to meet the needs of the residents. New staff have to complete a detailed induction programme and provide written evidence of their Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 19 learning. All staff have a learning portfolio which includes their individual learning objectives. The recruitment records of recently employed staff demonstrated that there are thorough and robust recruitment procedures in place with all the expected checks being carried out before they start work at the home. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The interests of the residents are seen as very important to the manager and the staff. EVIDENCE: The acting manager had just been confirmed as permanent manager at the home and was advised about the process of becoming registered as manager with the CSCI. She is an experienced nurse who has worked for the company for a number of years and has been a unit manager at another home before coming to manager Elmwood in December 2006. She does not have a qualification in management and intends to register to do the Registered managers’ Award (RMA) as soon as possible. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 21 The manager has an open approach with the residents and staff and is a good communicator. She has held meetings with the staff and residents since taking up post and notes were seen of the meetings. There is a well established programme of ongoing audit for example, monthly audits are carried out of the care plans, medications and of kitchen practices. Monthly returns are also required to be sent to head office regarding, for example, accidents and complaints. Satisfaction surveys are also sent out on an annual basis. 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. The financial records are subject to external audit. Mandatory training has been provided to all staff and includes manual handling and moving and fire training. Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X 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 2 X 3 X 3 X X 3 Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations The manager should make sure that the information in the care plans is relevant and up to date to make sure that care needs are not overlooked. The manager should continue to work with her staff in developing a more person centred approach to care planning. The manager should make her application to be registered with the CSCI as soon as possible. The manager should undertake the RMA as soon as is possible. 2 OP31 Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elmwood Nursing Home DS0000001339.V327982.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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