Inspection on 07/07/05 for Elpha Lodge Residential Care Home Limited

This inspection was carried out on 7th July 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 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

Elpha Lodge Residential Care... 16/06/09

Elpha Lodge Residential Care... 19/04/07

Elpha Lodge Residential Care... 17/01/06

Elpha Lodge Residential Care... 09/12/04

Elpha Lodge Residential Care... 29/06/04

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

CARE HOME ADULTS 18-65 Elpha Lodge Residential Care Home South Broomhill Morpeth Northumberland NE65 9RR Lead Inspector Elaine Wright Unannounced 7 July 2005 10:45 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elpha Lodge Address South Broomhill Morpeth Northumberland NE65 9RR 01670 760397 01670 761351 elsie@elpha.totalserve.co.uk Ms Elsie Hazel Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs N Nicholson CRH 24 Category(ies) of PH Physical Disability (21) registration, with number PD(E) Physical Disability (3) of places Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. (Main building) Physical disability (12), Physical disability over the age of 65 years (3). 2. (Sydney House) Physical disability (9). Date of last inspection 9 December 2004 Brief Description of the Service: Elpha Lodge is situated on the outskirts of South Broomhill, near Morpeth, and is within walking distance of local shops and community facilities. The home is a short distance from Amble on an accessible bus route. Twenty four younger adults with a physical disability or illness live at Elpha Lodge. Three service users are over the age of 65 years. The accommodation is split between Elpha Lodge and the newly built Sydney House which provides en-suite accommodation for 9 service users. The majority of accommodation is at ground floor level. There are three double bedrooms in the main building. The home has its own mini bus which enables service users to access college, social events and outings. Nursing care is not provided. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Elpha Lodge and Sydney House was carried out by Elaine Wright on Thursday 7 July 2005, at 10:45, and lasted for 5 hours. The manager Nicola Nicholson and her deputy Jane Whitfield were present during the inspection. The inspection focused on the small number of requirements and recommendations made at the last inspection and key standards linked to premises, hygiene, safe working practices, health care, medication, concerns/complaints and protection of vulnerable adults (POVA). The inspection comprised a full tour of both Elpha Lodge and Sydney House which included communal areas, kitchens, laundry, bathrooms and bedrooms (with the agreement of service users), discussions with service users and staff, examination of service users care plans, risk assessments and activity/social opportunity notices, random check of medications and associated records. The manager accompanied the Inspector on the tour of the premises and pointed out repair and replacement work that had been recently undertaken including the replacement of windows to the rear of the premises. What the service does well: What has improved since the last inspection? Recording of service users involvement in their care plans. Replacement of windows to the rear of Elpha Lodge with UPVC double glazed units. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 6 The manager is carrying out and recording her own random audit checks on medication systems within the home. 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. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were inspected on this occasion. Standard 2 will be looked at during the announced inspection later in the year. EVIDENCE: None. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9. Service users sign their agreement to recordings in their care plans which support them to make decisions. Service user choices/decisions are promoted widening their opportunities to engage in socially and educationally appropriate opportunities and activities. Risk assessments reflect the decision making process protecting the health and welfare of service users. EVIDENCE: Records examined included evidence of service users and their families involvement in reviews and care planning. Service users sign their individual care plans and risk assessments. Staff have under gone training to enable them to deal with any behavioural issues that may arise. Staff were observed enabling service users to make decisions/choices with regard to their daily life. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 10 Service users confirmed that they had made choices about which activities and social events they wished to take part in. The home retains information on each service users file in the event of a “missing person” incident. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 Activities and social opportunities are encouraged and advertised within the home enabling service users to mix with their peer groups outside the home. EVIDENCE: A beauty therapist visits the home each Tuesday and Wednesday. Events advertised on the home’s notices boards included – concerts, pantomimes, circus and theatre events. Between 3 and 9 service users had already put their names down to take part in these events. Service users confirmed during discussion with the Inspector recent pop concerts and social events that they had taken part in. Visits to college had been undertaken to ensure service users were able to enrol in their courses for 2005/06. Service users get one free outing in the home’s transport each week and anyone wishing to attend church does not have to pay for transport. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 12 Other transport costs are dependent on whether the car or mini bus is used and how many service users are going out. There are no charges for journeys in the local area and the manager audits charges to service users on a monthly basis and regularly checks these against the cost of public transport and local taxis. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21. Personal care is delivered in a manner that promotes service user privacy, dignity and choice. Access to appropriate professional support ensures the physical and emotional health needs of service users are well managed. Medication systems within the home promote the health, wellbeing and safety of service users. EVIDENCE: Service users have a nominated key workers who is involved with the planning and delivery of their care. Records indicate service users preference with regard to bathing and dressing issues. Service users can access baths and showers as frequently as they wish. Excellent working relationships have been established with a wide range of appropriate professionals including psychiatrists, OT’s, general practitioners and specialist nurses. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 14 A random medication check was carried out in Elpha Lodge and no discrepancies were identified. The manager is carrying out and recording her own random audit checks and these were available to the Inspector. Homely remedy agreements were in place. Handwritten recordings on the medication administration recording sheets were double signed and dated. Service users wishes in the event of their death are recorded in personal section of their file which can be easily accessed in an emergency. The local health centre offers a counselling service for both staff and service users and the majority of staff have also undertaken training in this area of care. Where necessary service users are enabled to make a will. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The systems in place promote and encourage the complaints process protecting the welfare of service users. Vulnerable adult procedures and training promote the welfare and safety of service users. EVIDENCE: Systems are in place for the acceptance, recording, investigation and reporting of complaints. The above system is supported with clear procedures for dealing with any allegation/disclosure of possible abuse. Policies and procedures are in place to support both complaint and vulnerable adult arrangements. All staff must have an enhanced Criminal Records Bureau check before they are able to commence work. The manager records the date the check is applied for and returned and retains checks obtained between inspections. At each inspection the Inspector has been asked to “sign off” checks in order that these can then be destroyed. The system adopted is clear and effective and provides a good record for audit purposes. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30. The home is clean, tidy and well furnished in a manner that promotes service users independence and their safety. Bathrooms and toilets, both communal and en-suite facilities, are warm, clean, hygienic and well equipped promoting the health, safety and welfare of service users. Bedrooms throughout the home create an independent and safe environment for service users. Installed equipment promotes the independence and safety of service users and safety of staff. The high standard of cleanliness within the home promotes the health, welfare and well being of service users and staff. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 17 EVIDENCE: Elpha Lodge The rear fire escape is in need of repair or replacement. The handrails were loose, areas of wood were rotting and the paintwork was in need of renewing. General and clinical waste bin storage had been provided to the rear of the premises which is a great improvement. The “nurse” call system was checked in each service users bedroom. One push cord was found to be faulty but this was replaced immediately. Small areas of damp were identified in two bedrooms on the first floor. It was unclear whether this was just staining from a previous repair or a new problem. Pull cords were missing for over bed lights in one first floor bedroom. Where appropriate alternative means of accessing light have been explored and installed, for example, a touch light. All bedrooms had individual supplies of towels and face clothes for the use of service users. Paper towel and soap dispensers were available in all communal bathrooms and toilets. The COSHH storage area and cleaning cupboards were accessible, very tidy and contained appropriate guidance for staff on the use of substances hazardous to health. The laundry (which is locked when staff are not present) is well equipped and was found to be exceptionally clean and tidy. Service users have access to a “smoking room” at ground floor level. The kitchen was found to be clean and tidy in the main however a deep fat fryer and mechanical ventilation unit were identified as needing to be cleaned. The manager requested staff to carry out these tasks as soon as possible. Butcher meat in the freezer was found to be undated and labelled. The food store was clean and well stocked. Menus are completed on a daily basis and returned to the manager monthly. A new food probe for de-frosted Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 18 food and cooked meats has recently been replaced and policies include clear guidance for storing cooked food and reheating. Sydney House The kitchens within Sydney House are of a small domestic household nature and service users can easily make themselves a snack or drink as they wish. The integrated refrigerator door in one of the kitchens was in need of replacement or repair. Separate hand washing facilities are provided in both kitchen areas. All the bedrooms in Sydney House have en-suite – shower, toilet and wash hand basin – facilities. Where necessary assisted bathing and toilet equipment has been provided. The house also has assisted bathing facilities. Service users had recently voted on the colour scheme to be adopted in the communal areas of Sydney House and they had all chosen a colour scheme for their bedrooms. In one bedroom exercise bars had been installed at the service users wish. Four service users have had Sky TV in their bedrooms and all have music, DVD and video equipment. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 Systems for the recruitment and selection of staff promote the health, safety and welfare of service users. EVIDENCE: The manager has been in discussion with an recruitment agency with a view to employing two foreign workers on her staff team. Enquiries through the agency have been thorough, have explored employment legislation and the obtaining of the equivalent CRB checks. The manager is aware of her responsibilities in respect of foreign workers and the company is making arrangements to introduced them to local health facilities and banks and will also arrange for accommodation. Cultural and religious issues have been fully explored and discussions are to take place with service users and their families prior to the new workers being introduced. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 40, 41 and 42. The effective use of policies, procedures and systems within the home promotes the health, safety and welfare of service users. The experience and qualifications of the manager and staff promotes the interests and rights of service users. EVIDENCE: The rear fire escape is in need of repair or replacement. The manager is well qualified and experienced to carry out her role and cooperates fully with CSCI, consulting openly as necessary. She is currently working to complete her NVQ level 4 and Registered Manager’s Award. During the inspection all records viewed were found to be up to date and in good order. A copy of the latest inspection report and insurance cover were displayed in the entrance hall. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 21 Relationships between the manager, staff and service users remain warm, friendly, supportive and are based on a sound knowledge of individual service users needs, wishes and preferences. A comprehensive range of policies and procedures are available to staff and are regularly reviewed. Door wedges previously in use in the home have been removed and door guard’s fitted. Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 x x x x x Standard No 31 32 33 34 35 36 Score x x x 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elpha Lodge Residential Care Home Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 3 2 x B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 23 NO Are there any outstanding requirements from the last inspection? 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 24 and 42 Regulation 23 Requirement Rear fire escape must be repaired or replaced. Damp patches in first floor bedrooms must bed investigated and repaired. Pull cords for over bed lights must be replaced. Deep fat fryer and mechanical ventilation units must be cleaned. Refrigerator door must be repaired or replaced. Butcher meat received into the home must be dated and labelled before freezing. Timescale for action 30 September 2005 2. 24 and 42 13 30 July 2005 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 37 Good Practice Recommendations Manager to obtain NVQ level 4 and RMA by 31 December 2005. B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 24 Elpha Lodge Residential Care Home Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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. Extracts may not be used or reproduced without the express permission of CSCI Elpha Lodge Residential Care Home B53-B03 S631 Elpha Lodge V229842 070705 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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