Inspection on 14/11/07 for The Elms

This inspection was carried out on 14th November 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 24/03/09

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Elms 34 Elmgrove Road Gorleston Great Yarmouth Norfolk NR31 7PP Lead Inspector Hilda Stephenson Unannounced Inspection 14th November 2007 09:30 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 The Elms DS0000070380.V354826.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. The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms Address 34 Elmgrove Road Gorleston Great Yarmouth Norfolk NR31 7PP 01493 657069 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) irenebeck@btconnect.com The Elms Residential Care Home Ltd Susan Burridge Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service: Care Home - PC to service users of the following gender: Both whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - code OP Date of last inspection 2/5/07 Brief Description of the Service: The Elms is a converted property registered as a care home to look after 21 older people. It is situated in quiet street in Gorleston near Great Yarmouth. Since the previous inspection in May 2007 there has been a change of proprietor who is now Mr Paul Godfrey. The premises are over two storeys with access to the first floor by a shaft lift. The accommodation consists of 15 single bedrooms and 3 shared bedrooms. There are three lounge areas and one dining room. One of the lounges is currently used by residents who wish to smoke. The home has an enclosed garden surrounding the building, with a small area at the front for parking. The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to The Elms took place during the day on the 14th November 2007 as an unannounced inspection to check the key standards, after the home has recently undergone a change of proprietor. These standards were inspected, although not all the elements may have been examined. The evidence gathered to publish this report was obtained by speaking to nine of the eighteen residents, one visiting professional, three staff and the manager. Time was taken by checking through care records, medication records, policies and procedures, comments and information received prior to this visit. The home was found to be clean, tidy and free from odour. The majority of residents were either in their own bedrooms or sitting in the lounge areas. What the service does well: Residents are cared for in a homely environment within a residential area of Gorleston. Each bedroom contains resident’s personal possessions and is decorated according to their taste. The new Proprietor visits the home one day a week to offer support to the manager, staff and residents. The home has a small loyal staff team to care for the current eighteen residents now managed by a registered manager who has worked at the home for many years. Since the new owner took over they have invested in providing specialist equipment to enable the residents to be cared for adequately to ensure that nutritional needs, pain relief and pressure care is in place for those who are frail, within a homely environment. The home has an ‘open’ policy for the inclusion of views from residents and relatives, as the manager or her deputy manager is on duty most days of the week. Residents are encouraged to continue with their own hobbies and interests, with several going out on occasions. The Elms DS0000070380.V354826.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. The Elms DS0000070380.V354826.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 The Elms DS0000070380.V354826.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are visited by the manager, who assesses their individual needs to ensure the home can care for them. The home makes available clear written information for residents to make their decision to move into the home. EVIDENCE: Statement of purpose had been updated to include the details of the new registered proprietor and was available in the front hall. Last key inspection confirmed good practice with the admission process, with no further changes. Since the manager has been in post all prospective residents are visited by her either at the hospital or home to make an initial assessment of care and social The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 9 needs. This information is recorded on the pre-assessment format and included in the care plan. The manager collects further assessment information from social worker and hospital ward and this is also stored within the care plans. Spoke to latest resident to move into the home and the admission process followed the same procedure. He received a contract and the details of this were explained to him by the manager. A second new resident was also spoken to, who explained that her husband had been involved with the admission process, although she was also kept informed throughout and knew the home beforehand so opted not to visit first. Prospective residents are invited to visit the home before moving in, although the manager stated in the majority of cases the relatives visit the home beforehand. Staff on duty were spoken to and able to describe the importance of making new residents feel welcome by explaining the routine within the home and are offered assistance to make their own choices. The Elms DS0000070380.V354826.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The improvement in recording care plans continues, with residents having access to their own records. Residents personal and care needs are met. Medication procedures have become unsafe, with staff not signing each entry on the medication records making it unclear whether residents have been offered their prescribed medication. EVIDENCE: Each resident has an individual care plan, which is situated within there own rooms; copies are kept within the office. The care plan includes admission information, health, social and mental health care needs and risk assessments relevant to them, to enable them to be as independent as possible. Each care plan is reviewed with the resident and signed, which is good practice. Each plan includes a risk assessment of individual care needs, such as moving and handling, continence, trips and falls, and nutritional needs with weight management included. The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 11 Three care plans were checked and followed through by speaking with the same residents, these gave a clear insight to their individual care and social needs. Specialist equipment is brought into the home when it is required, the home has purchased a second hoist and a hoist is now situated on each floor. The records showed that other medical professionals GP’s, Dentists, Physiotherapist and Dietician visits residents when this is required, and the District Nurse is sought when the residents require nursing tasks, who also offers support to care staff. The medication records were checked of the three residents who were spoken to at length and a further five random records. The medication records contained a significant number of gaps where there should have been an entry by the member of staff administering the medication. This can cause risks to residents if the medication charts are not signed and the manager is required to audit this immediately. See requirements. It was recommended that the MAR (medication administration records) charts at the last inspection that the manager should include photo identity of the residents, it was seen that this had been carried out for approximately half of the residents, so the recommendation carries over. See Recommendations. The medication is stored in a mobile lockable trolley. The home has acquired a separate fridge to store medication at the required temperature. The home holds controlled drugs with storage and recording being adequate. The Elms DS0000070380.V354826.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to maintain contact with relatives and friends and continue with their own hobbies. The staff arranges a varied amount of social activities. All residents are offered choices of meals. EVIDENCE: Since the change of proprietor the home organised a Launch Party and invited relatives and friends to meet the new proprietor. The home was inundated with visitors and residents spoken to enjoyed the party and stated that ‘they felt included with some of the organisation’ and meeting the new proprietor, who now visits each week. One of the care staff has taken over the role to organise social activities, three times a week, leaving other care staff to continue with small one to one sessions with residents. A musical afternoon takes place most weeks when an outside musician visits to play requests. Individual activities take place such as reminiscence, cards and games. The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 13 Many of the residents ask to play bingo and this is arranged on a weekly basis, although those who do not wish to take part have their choice respected. The manager confirmed that an extra member of staff is brought in when outings and events are arranged. It was the cook’s day off and the second cook who is also the deputy manager was preparing the main lunch with two other alternative main meals. A menu was supplied prior to inspection that looked varied and nutritional, with fresh vegetables and fruit used frequently. The kitchen was clean and tidy. The cook follows a two weekly menu, which is adapted throughout the seasons. Many of the meals have been taken from resident’s preferences. The cook confirmed that she visits each resident everyday to get their choice for the day, and the residents who were spoken to confirmed this. Lunchtime was a sociable event with the majority of residents going to the dining room for their meal. The Elms DS0000070380.V354826.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are listened to and feel safe within the home. EVIDENCE: The complaints log was seen. The home has received two complaints since the previous inspection, one was unsubstantiated and the second was currently being investigated. Each resident has a complaints form in their own room within the care records, to enable them to highlight any concerns they may have. The majority of residents spoken to preferred to speak to the manager, deputy or proprietor if they had any concerns, although the majority felt safe and listened to, there were no complaints during the day of inspection. A copy of the complaints procedure is displayed in the front hall. The home has an adult protection policy in place. This is discussed with staff when they commence employment. The majority of the care staff have attended local adult protection training, although this is recommended to be updated, in particular how the whistle blowing procedure should be used due to the nature of two previous complaints sent direct to CSCI. See Recommendations The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 15 Staff spoken to had a basic understanding of adult protection. The manager and deputy have attended POVA training and have a clear understanding of their role within the care field. The manager follows a clear recruitment procedure by checking staffs suitability to work with adults prior to employment, by obtaining their POVA and CRB checks beforehand. The Elms DS0000070380.V354826.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and well-maintained home. EVIDENCE: The home is clean and tidy and accessible to residents throughout the premises. The main lounge and dining room contained homely individual furniture. The rear lounge has been adapted to accommodate residents who smoke. The requirement issued at the last inspection has been completed with magnetic door catches added to resident’s doors that wish to leave them open. When the fire alarm is triggered these doors automatically close. The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 17 The manager has drawn up an improvement plan. Since the new proprietor took over the home, several areas have been improved. There have been five electric adapted beds now in use for resident’s comfort. The bedroom doors have numbers added to them, a second hoist and digital camera has been purchased. Two first aid boxes are now situated on each floor. Staff now wear name badges, which was suggested by residents after the last quality assurance survey. The home continues to launder resident’s clothes. The Elms DS0000070380.V354826.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well-trained competent staff cares for residents. EVIDENCE: There was sufficient staff on duty that was competent to fulfil their roles. Two members of staff were spoken to both had achieved the NVQ level 2 with one having level 3. They both spoke of the training courses they had attended with dementia care being the latest. The training records corresponded with the training that they had undertaken. The home had over half of the care staff that had achieved or were undertaking the recommended NVQ training. The training and supervision records were seen along with the initial induction training records. The last member of staff employed at the home was a carer and the manager had followed a good clear recruitment procedure, obtaining references and crb (criminal records bureau) before staff commenced. It was observed that the call bell did not ring for long when residents wanted some attention from staff. The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 19 The manager is supported by a deputy manager who shares some managerial responsibilities and between them they are on duty most days. It was noted that staff expressed their satisfaction of their job role and the amount of support they received from the manager. Staff meetings were held quarterly with smaller informal meetings during the year. Minutes were taken at all the meetings so staff could catch up. The Elms DS0000070380.V354826.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is managed with their best interests at heart. Resident’s health, welfare and safety needs are promoted and protected. EVIDENCE: The manager is currently undertaking the NVQ4 in management. She regularly attends training to keep up to date. Staff meetings are arranged every 3 months with minutes recorded. Staff supervision is carried out with records in staff files. The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 21 The manager has arranged residents and relatives meetings with the next arranged for 23rd November to discuss changes and arrangements for the next big event, which will be Christmas. The manager and deputy manager manages the home in an open and friendly manner with one of them in attendance most days. The new proprietor supports both residents and staff during his weekly visits and undertakes an unannounced visit in accordance with Regulation 26. There is a quality assurance system in place with the results sent prior to inspection. Records show that health and safety issues are attended to with regular maintenance of fire equipment and training. The accidents and deaths rates at the home showed no abnormalities. Risk assessments for individual residents were seen in care plans, with general assessments following the homes policy and procedures to ensure the safety of the staff too. The home keeps some residents finances securely and random checks of these records were seen, which was satisfactory. The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 x 3 The Elms DS0000070380.V354826.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13.2 Requirement All entries on the medication records should be signed appropriately to reduce the risk of a medication error. Timescale for action 30/12/07 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 Refer to Standard OP9 OP18 Good Practice Recommendations All residents should have a photograph to identify them on the front of the medication records. All staff must have up to date adult protection training to ensure they understand the whistle blowing policy. 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