Inspection on 13/11/05 for Sutton in the Elms Nursing & Residential Home

This inspection was carried out on 13th November 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

Sutton in the Elms Nursing &... 22/04/08

Sutton in the Elms Nursing &... 08/08/06

Sutton in the Elms Nursing &... 09/08/05

Sutton in the Elms Nursing &... 10/12/04

Sutton in the Elms Nursing &... 20/07/04

Sutton in the Elms Nursing &... 22/03/04

Sutton in the Elms Nursing &... 10/08/03

Sutton in the Elms Nursing &... 19/11/02

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sutton in the Elms Nursing & Residential Home Leicester Road Sutton In The Elms Leicestershire LE9 6QF Lead Inspector Paula Dutton Unannounced Inspection 14th November 2005 09:20 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 Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.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. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sutton in the Elms Nursing & Residential Home Address Leicester Road Sutton In The Elms Leicestershire LE9 6QF 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) 01455 286577 01455 286578 DRE Group Limited Mrs Angela Margaret Lonsdale Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Physical disability (10), Physical disability of places over 65 years of age (10) Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person under 55 years of age who falls within category PD may be admitted to the home . No person to be admitted to the home in categories PD or PD/E when 10 persons in total of these categories/combined categories are already accommodated in the home. To be able to admit the named person of category PD named in variation application number V24401 dated 6 September 2005 09/08/05 3. Date of last inspection Brief Description of the Service: Sutton In the Elms Nursing Home is a purpose built modern property designed to accommodate up to 39 people over the age of 65years. The home is registered to admit up to 10 people with physical disabilites who are over 55 years of age. The property is situated in a rural village of Sutton Elms which is near to Broughton Astley village. This area can be easily reached via the M1 motorway and main routes. The rear of the property offers ample parking spaces and views of the countryside. All areas of the premises are accessible for people with mobility impairments. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of three and a half hours. The registered manager was available throughout the inspection process. Aspects of care provided to three residents were considered by the inspector. This included speaking with residents, viewing staff communicating and assisting residents, interviewing a senior member of staff and viewing care plans, risk assessments, admission assessments and daily notes. Discussion took place with the manager and the Chef about how the home meets the needs of residents. This process of gathering information is known as ‘case tracking’ and measures outcomes for residents. This inspection report should be read in conjunction with the previous inspection report. What the service does well: What has improved since the last inspection? What they could do better: There were no shortfalls identified during this inspection therefore there were no statutory requirements or recommendations issued. Some discussion took place with the manager about the use of wheelchairs without footplates and the system of formal and recorded supervision. A commitment was made by the organisation to address these issues. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 6 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. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.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 Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Information is exchanged prior to admission to ensure potential residents are able to make an informed decision about moving to the home. EVIDENCE: The manager demonstrated that information about a potential resident is gained prior to admission so that the home can assess whether or not the individual’s needs can be met. A resident had been recently admitted to the home. An individual record file contained an assessment completed by the manager plus a copy of an assessment undertaken by a social worker. Evidence showed residents are offered the opportunity to visit the home before making a decision to move in. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.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, 10 Residents’ health, social and welfare needs are met. EVIDENCE: Two care plans were viewed. These showed residents’ identified needs and the actions to be taken to meet those needs. These included instruction to address high risk needs such as minimising the risk of falls through safe moving and handling practices. The accident record book was viewed. Accidents were recorded individually. There had been a low number of falls/slips over the previous three months. Observation found residents were assisted to move safely at lunchtime into the dining areas. Residents were assisted in a dignified and unhurried manner. However one resident was observed being transferred in a wheelchair using only one foot plate. The resident did not object to this and was able to rest both feet on one footplate. The manager agreed this was not safe moving and handling practice. This matter was addressed by the manager during this inspection. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 10 Care plans included instructions for the management of continence. Discussion took place with a senior member of staff who demonstrated a good working knowledge of how urinary infections affect residents and how to prevent infections. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents receive a varied and nutritious choice of foods. EVIDENCE: The home offers two dining areas that are well presented and pleasant environments. Observation found residents were seated comfortably and able to express preference as to where they would like to sit. Discussion took place with the Chef who demonstrated a very good working knowledge of the nutritional needs of residents. The chef was aware of residents’ personal needs and preferences. The chef meets with residents at residents’ meetings but also comes into the home to talk to residents. This is good practice. Evidence indicated the home monitors residents’ nutritional needs including within care planning, recording weight, daily notes and through risk assessment. The chef was aware of the needs of residents who had swallowing difficulties. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.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, 18 Residents are able to express their opinions and have their rights protected. EVIDENCE: The home has a robust policy and procedure for receiving complaints. Discussion with the manager established the home welcomes comments or complaints as part of the ongoing commitment by the home to continuing improvement of services. Evidence presented on inspection showed the manager takes complaints very seriously and responds promptly to concerns raised by residents and their relatives. A discussion with a senior carer found the home promotes learning about the prevention of abusive practices through attendance on National Vocational Qualification training. This member of staff was aware of the different types of abuse and the Department of Health’s guidance document entitled ‘NO SECRETS: Mistreatment of Vulnerable Adults’. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.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): THESE STANDARDS WERE NOT INSPECTED THIS TIME This service offers exceptional environmental standards as listed in the previous inspection report. EVIDENCE: Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.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, 30 Through careful recruitment, training and numbers of staff provided residents’ needs are met and their safety ensured. EVIDENCE: Evidence within a staff file showed the home follows a careful recruitment procedure including gaining two written references and completion of a Criminal Records Bureau check. Discussion took place with the manager about planned ongoing recruitment in which the manager has primary lead. A rota showed sufficient staff are provided to meet the needs of residents. Evidence showed staff are deployed according to times of peak activity. The manager stated there is a programme of ongoing training for all staff. A discussion with a member of staff confirmed training is offered to staff including National Vocational Qualification training. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 36 Effective communication within in the home ensures residents’ needs are met safely and effectively. EVIDENCE: The manager operates an ‘open door’ policy for all staff and residents to access the manager at any time easily. Observation at the time of inspection found staff were able to approach the manager to raise enquiries. The manager was readily available and responded to staff when requested. A general staff meeting was planned for the next day. A discussion took place about formal and recorded supervision. Currently the home instructs staff in their care practices through structured induction and training. Recorded observational supervision takes place for specific care tasks. Examples were notes for nurses observing care staff in tasks such as catheter Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 16 care, pressure area management and checking blood sugar levels. The manager stated the home is currently reviewing the system of formal and recorded supervision in line with Standard 36 of the National Minimum Standards for Older People. Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X 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 X 3 X X X 3 X X Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 18 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. Refer to Standard Good Practice Recommendations Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Sutton in the Elms Nursing & Residential Home DS0000001927.V265873.R01.S.doc Version 5.0 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!