Inspection on 10/04/07 for The Elms

This inspection was carried out on 10th April 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

The Elms 04/05/06

The Elms 05/10/05

The Elms 27/04/05

The Elms 16/11/04

The Elms 17/06/04

The Elms 23/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Elms, The The Elms 13 Regent Street Bilston Wolverhampton West Midlands WV14 6AH Lead Inspector Mr Ian Harris Key Unannounced Inspection 10th April 2007 08:00 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 Elms, The DS0000020887.V335105.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. Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elms, The Address The Elms 13 Regent Street Bilston Wolverhampton West Midlands WV14 6AH 01902 491890 01902 408875 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) Mr Jagjit Singh Surae Mrs Charn Kaur Surae Susan Nelhams Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Females 60 years and males 65 years and above. Date of last inspection 4th May 2006 Brief Description of the Service: The Elms is a large detached property situated in a residential area of Bilston. The home is currently registered for 13 older people by the joint- owners Mr and Mrs Surae. There are eleven single bedrooms, four of these with en-suite facilities and one double bedroom. The home has an adequate garden and car park space at the rear of the building. There are adequate number of bathrooms/showers and WCs. There is a lounge and a dining room, which have been recently redecorated. The kitchen is fully equipped. There is a laundry room. The Home is in close proximity to all of the local amenities, which includes the health, leisure and community centres, a park, a library, shops and a market and access to public transport i.e. buses and Metro. At the time of this inspection the weekly fees for care ranged from a minimum £319.00 per week up-to a maximum of £328.00. Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 5 hours. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 3 members of staff and 6 residents were spoken to. Six case files were selected for case tracking, relevant documents were inspected and discussions were held with residents, and members of staff. Observation was made of the various daily activities. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. All the residents spoken to who could express themselves in a meaningful way expressed their satisfaction with the care they received and there were comments as follows “the food is good here” “The staff are very kind” “ I’m very settled and I like my room, this is a very nice home.” “I like the company”. What the service does well: The atmosphere within the home is comfortable and friendly and there is friendly rapport between service users and staff. Meals are varied, well balanced and presented to meet each individual’s choices, preferences and requirements. The home communicates well with families/friends and representatives of the residents and there are regular visitors. The residents spoken with said that they are happy and content with living in a homely and caring place. The residents were in the lounges engaging in their daily routines and activities and they further commented that they were comfortable and satisfied with the care provided. The home has a good staff- training programme, which all staff are involved in, this ensures that they are improving their knowledge and skills to meet the changing needs of the residents. Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 6 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. Elms, The DS0000020887.V335105.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 Elms, The DS0000020887.V335105.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): 3 The quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. Standard 6 could not be looked at because The Elms does not provide an intermediate care service. The home has a good admissions procedure ensuring the individual needs of the residents are fully met. EVIDENCE: Six case files were selected for inspection and included files of people recently moving into the home. There is evidence on the files that all the residents who are funded by the Local Authority undergo a full multi-disciplinary assessment prior to admission. The residents, who are self funding are assessed by the Care Manager, using the home’s assessment forms. There was evidence on one case file that the manager had visited a prospective resident, before a placement was offered; this ensured that the Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 9 home would be able to fully meet the assessed care needs. Two residents confirmed that their daughter had brought them to the home to view the bedroom and they stayed for lunch and met some of the residents and staff. Pre admission details were included in the other files together a record of trial visits to the home, details of assessed care needs and an environmental pre admission audit. One resident stated that she made the decision to move into the home permanently ’ I didn’t want to go any where else… I like it here’. Elms, The DS0000020887.V335105.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 The quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. Each resident has an individual care plan, which is written in plain language, easy to understand and reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements being in place to ensure resident’s medication needs are met. EVIDENCE: The home provides a comprehensive care plan for each individual resident, which is written in plain language, easy to understand and based on the initial assessment. The care plans are drawn up by the care staff in consultation with Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 11 the resident and their family. There was evidence on the files to show the care plans are being carried out and reviewed on a monthly basis. The home is well supported by local G. P. s. and all of the paramedical services. Wherever possible, the residents are encouraged to retain their own G. P s, Opticians, and Dentists. It was noted that if the resident has moved out of their area the Care Manager ensures that, these services are provided by local practitioners. The records indicate that resident’s medical needs are being met and this was confirmed by two residents. Medication is administered by means of a Boots monitored dosage system. The system appears to be working very well, ensures medications are handled safely and residents get the medications they have been prescribed. The home receives good support from the Boots pharmacist who does a three monthly audit of the homes medication. All care Staff have been trained to use the system before they are allowed to administer medication. All the residents have single rooms with a wash-hand basin four have ensuites. Particular attention is given to ensuring privacy and dignity when delivering personal care. Observation of the working practices of three carers throughout their morning shift confirmed they were courteous and attentive to the individual needs of the people living at the home. All of residents seen were well groomed and attired. No personal care interventions take place in communal areas. Observed practice on the day of inspection was appropriate and showed respect for the residents. Two of the residents who could express themselves in a meaningful way said that the staff were very helpful and kind. Elms, The DS0000020887.V335105.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 The Quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. The home provides a programme of social activities within the home, which is designed to meet the resident’s capabilities, which, the staff encourage residents to pursue. The Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The meals in the home are good, offering choice and variety, and also catering for special dietary needs. EVIDENCE: The Home works hard to involve residents in a range of leisure opportunities, consistent with each resident’s capabilities, which is very limited due to their age and frailty. The manager and deputy manager ensures there are a variety of things for residents to do as a group or on their own. It was noted that the Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 13 people who currently live at the home have enjoyed craft sessions, musical evenings, reminiscence groups, keep fit exercises and sing a-longs. The Registered Manager stated that the residents are positively assisted and helped to exercise choice and control over their lives and there is evidence that regular residents meetings take place. A close liaison is maintained with the relatives and representatives, where the residents are not able to make certain decisions. Staff at the home encourage regular contact between residents’ and their relatives by inviting them to parties, fetes, outings and celebrations. All residents’ comments were very complimentary about the standard and choice of food provided. It was noted that the menu for the main meal of the day is changed to incorporate seasonal variations. Several residents told the Inspector that the food was nice, tasty and well prepared. The kitchen is well equipped, kept clean and tidy. The catering staff are trained in food safety and hygiene matters. Elms, The DS0000020887.V335105.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 17 The quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. Residents and others involved with the home understand how to make a complaint and are clear about what will happen if a complaint is made. Residents are well protected by a robust prevention of abuse policy and procedure. EVIDENCE: The home has a good comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide, of which a copy is placed in every bedroom and on the notice board in the reception hall. A number of residents stated if they had any problems the Manager would sort it out for them. The home has a complaints book in which all complaints are recorded. It was noted that the home has not received any formal complaints since the last inspection all minor complaints are dealt with appropriately and quickly. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which, includes a WhistleElms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 15 Blowing policy. These issues are also covered in external and N.V.Q. training, which all care staff have undergone. Elms, The DS0000020887.V335105.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 The quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home and the garden is good providing the residents with a very attractive, comfortable, homely and safe place to live. The residents live in an environment that was found to be clean tidy and free of unpleasant odour. EVIDENCE: The home is long established and has been adapted in order to provide appropriate accommodation for older people. The home is maintained to a Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 17 good standard, and provides a very comfortable homely and safe place for the residents. There has been considerable work carried out in the home since the last inspection, which includes the redecoration of the hall/reception area, ground floor corridor. a bathroom has been converted into a shower room and the exterior of the building has been redecorated, and the gates, car park and fences have been repaired. Tables, and lockable draws have been provided in the rooms that did not have them and a new refrigerator has been purchased for the kitchen. All the shared spaces within the home provide a warm, friendly, safe and comfortable environment. Residents’ bedrooms have been personalised with their own personal possessions. This gives the appearance of a very comfortable environment. The home is in compliance with the Fire Safety Officer’s requirements. During the inspection, the home was found to be clean, tidy and free from any unpleasant odour. The home has good policies and procedures in place regarding infection control. The Registered Provider stated that the majority of staff have received training in infection control and they are made aware of the dangers of cross-infection. Elms, The DS0000020887.V335105.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 The quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. Residents receive support from a sufficient number of staff who have a good understanding of their needs. These staff are recruited and trained properly and this helps to ensure that residents are safe and well cared for. EVIDENCE: The inspection of staff rotas and discussions with staff and residents indicated that the home is well staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. It was noted that there have been minimal staff changes since the last inspection. Discussions with six residents in a group confirmed they thought the staff were respectful and helpful. Observations of staff carrying out a variety of tasks appeared to confirm they are clear regarding their role and what is expected of them. Residents report that staff working with them, know what they are meant to do, and that they are able to meet their needs. The home operates an efficient recruitment procedure. On inspecting 6 staff files, there was evidence within them that all C.R.B. checks are being carried Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 19 out. All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has a programme of N.V.Q. training that has exceeded the minimum standard. Also the care staff have attended courses on Safe handling of medication, Infection control, Moving and handling, Risk assessment, Food Hygiene, First Aid and Health and safety at work. The home has also introduced a new induction programme that meets the Skills for Care standards. Elms, The DS0000020887.V335105.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 The quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a competent registered manager. Service users’ interests and welfare are promoted. The home has good policies and procedures regarding Health and safety and meets the requirements of the Fire Officer and Environmental Health Officer, promoting a safe environment for the residents EVIDENCE: The Care Manager has the Registered Manager’s Award and considerable experience in caring for older people. There are clear lines of accountability Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 21 within the home and the manager is very supportive of both staff and residents. Observations made and discussions with residents’ and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residents who could express themselves stated that they are happy to approach the Care Manager and staff with any problems they might have and were confident that they would be responded to. There is a good staff supervision system in place and there is evidence that the staff have regular supervision meetings. It was also noted that the home has a Quality Assurance system in place, which includes questionnaires to residents, visitors, other professionals and relatives to obtain feedback on the quality of service. The feedback from the last issue was very positive regarding the care they are receiving. However an action plan should be produced to address issues raised by the feedback. The routines and activities within the home are flexible and built around the needs of the residents. All the financial records and administrative procedures within the home that were inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All recommendations and requirements made at the last inspections of the Fire Prevention Officer and Environmental Health Officer have been actioned. All safety equipment is regularly checked and well maintained. Elms, The DS0000020887.V335105.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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 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 3 X 3 X 3 X X 3 Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 23 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. 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 OP30 Good Practice Recommendations The Registered Providers should consider making provision for specialist training in management of challenging behaviours, dementia care, and disability awareness. To develop the skills of the staff. The Registered Providers should consider providing training in safe handling of medication to care staff who as yet have not received this mode of training as a matter of good practice. The registered person should develop an action plan from the quality assurance findings in order to respond to residents/ relatives’ comments. 2. OP9 3 OP33 Elms, The DS0000020887.V335105.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Elms, The DS0000020887.V335105.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. 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!