Inspection on 24/05/05 for Elton Hall Care Home

This inspection was carried out on 24th May 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

Elton Hall Care Home 29/01/07

Elton Hall Care Home 27/02/06

Elton Hall Care Home 06/10/04

Elton Hall Care Home 14/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Elton Hall Care Home Elton Hall Elton Village Stockton-on-Tees TS21 1AG Lead Inspector Brenda Grant Unannounced 24 May 2005 09:40 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 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. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elton Hall Care Home Address Elton Hall Elton Village Stockton-on-Tees TS21 1AG 01642 570200 01642 583218 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) Bond Care Ltd Mrs Victoria Hutchinson Care Home 76 Category(ies) of DE(E) Dementia - over 65 registration, with number PD(E) Physical dis - over 65 of places OP Old age Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named individuals who are under the age category are allowed to reside in the home. Date of last inspection 6th October 2004 Brief Description of the Service: Elton Hall Care Home is a 76 bedded home for 43 older people and 33 older people with dementia. Elton Hall Care Home is a modernised stately home, set in its own extensive grounds, bordered by woodland and open countryside. The home is less than two miles from Stockton-on-Tees. The home retains many of its original features. There are large lounges and an oak panelled dining room. The building is centrally heated throughout. Access to the first floor is either by a five-person lift or one of the staircases. The home has a south facing sun terrace that overlooks the rose gardens. Elton Hall Care Home has both single and shared bedrooms, all of which have an en-suite with a toilet and washbasin. All bedrooms, bathrooms and toilets are equiped with a call alarm system. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours, the inspector looked around the building and the grounds of the home as well as inspecting a number of records. 10 service users, 2 visitors, 3 staff, the manager and the regional manager were spoken to. Management and staff have addressed most of the requirements, from the last inspection. Service users told the inspector they were comfortable living at the home and they thought they were well care for. Visitors said the home “had a friendly atmosphere.” What the service does well: What has improved since the last inspection? The home has issued all service users with a contract or statement of terms and conditions. Service users Care Plans are reviewed every month and there are formal reviews on a yearly basis. The home has evidence that staff have undergone checks with the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults (POVA) list is checked, by the manager, within days of an application being forwarded to the CRB. The home has a ramped access to the rear garden. The home has made arrangements for service users to safely prepare snacks and drinks. The television in a lounge now has a clear picture screen. Two bedrooms have been redecorated. The home has collated information from the quality assurance survey and reported on the findings. One to one supervision of staff is now taking place but the home has not yet reached the target of supervision being at least six times yearly. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 6 One extra member of staff has achieved a National Vocation Qualification at Level 2. There is around 50 of care staff having almost, but not quite, completed that qualification. 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. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 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 standard(s) 2 & 3 Service users are admitted to the home after having an assessment of needs and that the home confirms those needs will be able to be met. All service users have a written contract/statement of terms and conditions with the home. EVIDENCE: The home had copies of service user’s Social Worker assessments. Service users said they and/or their family were involved with those assessments. The home also has its own assessment documentation that the manager or the deputy manager completed during a visit to potential service users, before admission to the home. The manager, or deputy manager, sign the assessment documentation confirming the home will be able to meet the needs of the service user. The home had signed contracts/statements of terms and conditions for service users living at the home. Where service users are unable to sign the document, a relative confirmed, s/he signed it on the service users behalf. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 & 10 Service user’s Care Plans identify health, personal and social care needs and inform how those needs are being met. Not all documentation, confirming the need for use of cot-sides, was in place. Service users, where appropriate, are responsible for their own medication and that service users are protected by the home’s policies and procedures for dealing with medicines. Except for one instance, service users were seen to be treated with respect and their privacy is upheld. EVIDENCE: Six service users said they had their own GP to meet service user’s health care needs. One service user said s/he had regular visits from a District Nurse and s/he was satisfied with the health care s/he receives. One service user said, “If I am ill the staff are very kind and call for a doctor for me.” All service users, spoken to, said they were happy about the arrangements to meet their health and personal care needs. One service user had cot-sides to protect him/her from falling out of bed. The home had carried out a falls risk assessment that confirmed the cot-sides were needed. However the home did not have the assessment confirmed by a health professional that cot-sides were needed. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 10 The manager said that presently no service users controlled their medication, either due to the service user’s lack of ability or service users requesting that the home takes care of such matters. The service users, spoken to, all said they preferred the home to look after their medicines. The home had risk assessment documentation available, to complete, to protect service users if they wished to control their own medication. Service users said staff were always helpful and treated service users with respect. Service users said they could stay in the privacy of their own rooms or go to the communal areas, as they wished. Staff said some service users preferred to have their meals in the privacy of their own room rather than going to the dining room. The home accommodated for those preferences. Staff were observed knocking on bedroom doors before entering the rooms, indicating they respected the privacy of service users. On the day of the inspection, a member of the care staff was assisting a service user to bathe but the bathroom door was slightly ajar. That would allow any passer-by to overhear any private conversation, between the carer and service user, or for a person to enter the bathroom uninvited. The manager said she would remind all staff that personal care is to be carried out in private. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 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 standard(s) 12 & 13 Service users lived their lives as they wished and service user’s social, cultural, religious and recreational needs are met. Service users maintained contact with family/friends/representatives and the local community as they wish. EVIDENCE: Service users said they had monthly religious services at the home. Service users and relatives said visitors were welcomed to the home at any time. One relative said she regularly took the service user out of the home, on fine weather days, “For a change of scenery.” The home’s activities coordinator, on the day of the inspection, did some hand and nail care with individual service users. The coordinator said she sometimes organised group activities, depending on what service users wished to do. One service user said s/he enjoyed gardening therefore the home built a green house for the service user to grow fruit and vegetables. All of the plants in and around the green house looked very healthy and should produce a good crop. The manager said the home, in future, may have transport available for service users to go on outings. Presently, service users, with support from staff, arrange transport for outings either individually or in groups. Most weeks the manager arranges for entertainment to take place in the home, she said that was to add an interest for those service users who do not normally wish to take part in other activities. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 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 standard(s) 18 The home makes every effort to protect service users from abuse. EVIDENCE: The home has policies and procedures for protecting service users from any form of abuse. The manager and staff confirmed they were aware of, and followed, the policies and procedures. During last year, following the outcome of a complaint, the home referred a former member of staff for consideration for inclusion on the POVA register. The incident resulted in the home instigating extra training for staff regarding Whistle Blowing and No Secrets to give further awareness to staff in their role to protect service users. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21 & 24 The home’s environment is safe and comfortable with the exception of some repair/maintenance/decoration work that needs to be carried out and replacement of a hall carpet. All bedrooms have an en-suite facility with a WC and washbasin and there are a number of WCs located near communal areas. The home has shower and bathing facilities, giving service users a choice on how they wish to bathe. Service users have personalised their bedrooms by with their possessions and small items of furniture giving a more homely atmosphere for their rooms. EVIDENCE: Service users said the environment was to their satisfaction and “very nice.” However, one service user said the house, built at the edge of the grounds, spoiled the view from the bedroom window. However the service user said s/he would not prefer to move to another room. Service users said they brought their personal possessions to the home and staff assisted service users to arrange them as they wished. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 14 The home employs a person to carry out general maintenance work. He ensures all safety checks are carried out and keeps those records up to date. Service users have access to all parts of the home. Since the last inspection a ramp has been built, to allow service users to access the garden at the rear of the home. The home has toilets near communal areas and bath/shower facilities are in various places around the home. All bedrooms have an en-suite. There were a number of areas around the home that were seen to be in need of repair, replacement or redecoration. • Paint peeling on some exterior paintwork and doors to a lounge and two WCs. • Two en-suites had stained ceilings and one en-suite had grubby walls. • One en-suite had no toilet roll holder and no mirror in the vanity unit. • A hall carpet was stained and another hallway had scuffed walls due to wheelchairs rubbing up against the walls. • A two adjoining WCs had been redecorated but the staining to the walls and ceiling have returned. • Two bedrooms had scuffed walls due to wheelchairs rubbing up against the walls. • A bathroom had no toilet roll holder. One bathroom had a broken bath panel and radiator cover and the light was not working. The Regional Manager said plans were being made to have a refurbishment programme, throughout the home, to make good all the work that was needed to enhance the environment. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The home follows the recruitment policies and procedures but confirmation of induction training is not available at the home but is kept by staff. There is enough staff on duty for the numbers and dependency levels of service users. Staff training is ongoing but as yet there are not 50 of care staff qualified at NVQ Level 2. EVIDENCE: The home had policies and procedures for recruitment of staff. Staff’s files had all of the relevant details including CRB and POVA checks. Staff confirmed they undergo an induction programme that is recorded but those records were not available at the home. Since the last inspection one Care Assistant has gained NVQ Level 2. The home does not yet have 50 of care staff that have the qualification. The manager said the home’s trainer is working towards that target and it should be achieved by the end of this year. Staff rotas showed the number of staff, day and night, were satisfactory. The home has a number of core staff who have worked at the home for many years, they oversee the work of junior staff. The staffing structure has been improved since the last inspection. Each of the two units has a manager, responsible to the registered manager, and they run the units. There are Senior Care Assistants who supervise the work of junior staff in the absence of the unit managers. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 36 Service users have an amount of input about the running of the home through the annual quality assurance questionnaires. The home has not developed an annual development plan that reflects the aims and outcomes of service users. The home does not hold regular service users meetings for service users to further pass on their views about the home. Staff’s one to one supervision is being carried out but it is not at least six times yearly. EVIDENCE: The home had carried out a quality assurance survey and reported on the findings. The questionnaires resulted in the manager taking action when service users were dissatisfied with any aspect of the running of the home. The manager said the home was in the process of having an annual development plan but it has not yet been produced. There was a record of service users meetings but they do not take place regularly, the last one was October 2004. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 17 Staff confirmed they are now receiving one to one supervision. The home has a record of all supervisions but they do not take place at least six times yearly. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 x x 3 x x STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x 2 x x 2 x x Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 19 yes 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 8 Regulation 13 Requirement The home must confirm that advice has been sought, from a health professional, there is a need to use cot-sides. Care staff must ensure that personal care is carried out in private. Some of the exterior woodwork, with paint peeling, must be redecorated. The stained hall carpet must have the stains removed or the carpet replaced. (Previous timescale of 31st January 2005 not met) The doors to a lounge and 2 WCs had peeling paintwork and the WCs had stained walls and ceiling, they must be redecorated. 2 en-suites had stained ceilings and 1 en-suite had grubby walls, they must be redecorated. 1 en-suite had no toilet roll holder and no mirror in the vanity unit, they must be replaced. The walls of a hallway and 2 bedrooms, damaged due to being scuffed by wheelchairs, must be redecorated. A bathroom had no toilet roll B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Timescale for action 15th July 2005 15th July 2005 30th September 2005 2. 3. 10 19 12 23 Elton Hall Care Home Version 1.30 Page 20 holder and another bathroom had a broke bath panel, loose radiator cover and the light was not working, they must be repaired and/or replaced. 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. 2. 3. 4. Refer to Standard 28 30 33 36 Good Practice Recommendations By 2005, there should be at least of 50 staff trained to a minimum of NVQ Level 2. The home should have evidence of staffs induction training. The home should hold regular service users meetings and produce an annual development plan. Care staff should have one to one supervision at least six times yearly. Elton Hall Care Home B51-B01 S59240 Elton Hall V227801 240505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale, Stockton-on-Tees TS17 6QX 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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