Inspection on 27/04/05 for The Elms

This inspection was carried out on 27th April 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

The Elms 10/04/07

The Elms 04/05/06

The Elms 05/10/05

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 The Elms 13 Regent Street Bilston Wolverhampton WV14 6AH Lead Inspector Bhag Jassal Unannounced 27 April 2005 09:00 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. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Elms Address 13 Regent Street, Bilston, Wolverhampton, WV14 6AH. 01902 491890 01902 491890 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) Mr Jagjit Singh Surae Mrs Charn Kaur Surae Tania Mason Care Home 13 Category(ies) of Older People (13) registration, with number of places The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/11/04 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 thirteen older people. 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. 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 the Metro. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.00 am and lasted 6hours and 45 minutes. Twelve places were occupied and one bed vacant. The inspection included discussions with service users, staff and relatives/friends. The daily routine were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside and facilities was also undertaken. What the service does well: This care home is registered for 13 older people. The home makes every effort to provide individuals with a good standard of care to meet individuals’ assessed needs following a care plan. The home has a good key worker and staff supervision system in place. The home communicates well with families/friends and representatives. The “Friends of The Elms” – a committee of service users’ relatives/friends also support the home and raise funds for service users’ entertainment/leisure activities. The service users spoken with said that they are happy and enjoy living in a homely and caring place. The service users were in the lounge engaging in their daily activities and they further commented that they were comfortable and satisfied with the care provided. The atmosphere within the home was found to be relaxed, comfortable and friendly. The friendly rapport was observed between service users and staff. Meals are varied, well balanced and presented to meet each individual’s preferences and requirements. The home provides spacious accommodation, which is being maintained to be a good standard. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 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 Elms E56 E01 000020887 The Elms V222728 UI 270405 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 The Elms E56 E01 000020887 The Elms V222728 UI 270405 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) 1, 3 and 5 The home has produced a revised draft Statement of Purpose for the home and a Service Users’ Guide for distribution. Service users are assessed before moving into the home. They are provided with the opportunity to visit the home to assess the quality, facilities and suitability of the home before their relative moves in. EVIDENCE: The acting care manager stated that drafts have been produced of the Statement of Purpose for the home and a Service Users’ Guide, which are still to be amended, updated and finalised shortly. A sample of three service users’ care plans and files were seen at the inspection. All contained evidence that the service users receive the benefit of a comprehensive assessment prior to admission. The acting care manager also carryout assessments and these details are documented on care plans, which are drawn up by the senior staff with the assistance from the service users and their relatives. There was evidence to show that all the service users have been provided with contracts. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 9 The home has a good admission procedure, which is made available to all perspective service users and their relatives. The acting care manager stated that relatives had viewed the home on behalf and/or with their elderly relatives prior to admission to The Elms. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The staff are aware and sensitive to the needs of each service user and meet these needs in a professional manner. There is a clear and consistent care planning system in place, which provides with the information they require to meet service users’ health and personal care needs. Lack of accredited training in safe handling of medication by care staff potentially could place service users at risk. EVIDENCE: There was evidence to show all the service users undergo a comprehensive assessment of their needs prior to admission to the home. A care plan is produced which is bases on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans are implemented. Three service users’ care plans were examined and these were kept up to date and reviewed on a monthly. The home maintains records of all health checks carried out by the doctors, opticians, dentists, district nurses and chiropodists. The home also ensures that nutritional screening is undertaken, including weight gain or loss records are maintained and appropriate action is taken if required. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 11 Case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medication care services are sought. It was observed on the day of inspection that no personal care interventions were taken in communal areas. In addition, consultations with the health and social care professionals are carried out within the service users’ bedrooms. The Inspector spoke at some length with six service users and all of them commented positively about their care and they felt that they have every thing that they need. Three service users stated that “ the carers are very good and kind as well and they look after us very well”. Two other service users said “the carers are always there to help us”. The service users have access to a payphone, which they can use in private. Staff observed during the inspection spoke respectfully to service users. Service users’ relatives who were present in the home stated that they can see their relatives in private if they wish. Individuals receiving care during the inspection were taken to their rooms and bathrooms. The acting care manager stated that accredited medication training for care staff is still to be provided. The senior carers have completed this training. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The Elms provides a good quality and unique lifestyle for the service users in residence. Meals at The Elms are of good homely type offering both choice and variety and catering for special dietary needs. EVIDENCE: The home has a varied plan of activities for all service users to take part in. Records of these activities enjoyed by the service users are being maintained. All the service users reported that they are in touch regularly with their friends and family members and spoke about their visitors and of “entertaining” them throughout their daily routine. The visitors’ book showed considerable activity. A relative of one of the service users stated that they visit at various times of the day as they wish. All the relatives and friends who spoke to the Inspector said they are given a warm friendly welcome by all the staff whenever they visit. The Treasurer of Friends of The Elms (service users’ families and friends committee) also stated that the home is a friendly and caring place for all the service users and all the staff are very caring and committed group of people. Everyone who committed on food said how good it is. Menus are balanced and interesting, and are flexible enough to accommodate individual preferences. Two relatives who were visiting their relatives stated that the food was very The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 13 good offering a good variety. Detailed records are kept that show that the service users’ particular preferences and special needs are catered for. Lunch was served during the inspection and it was well presented. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints system and there is evidence that the service users feel that their views are listened to and acted upon. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has a complaints procedure, which is referred to for information in the Service Users’ Guide. There is a system of recording complaints and it was noted that there were no entries. There have been no complaints directed to the Commission for Social Care Inspection within the previous 12 months. The service users spoken to by the Inspector stated that their views were always listened to by the management and staff. The home has policy and procedures in place with regard to the protection of service users from abuse. Staff were have been made aware of the adult protection issues and the procedures. The acting care manager stated that staff have also undertaken adult protection training. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 15 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, 21, 22, 24, and 25 The general standard of the environment is good providing service users with a homely place to live. The standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home offers a comfortable, pleasant, hygienic and well- maintained environment to all service users. The home has ample space for dining and lounge areas. Both of these areas have been redecorated and new dining furniture have been purchased. New carpet for the dining room is being replaced very shortly. Easy chairs in the lounge have been fitted with new covers. A new washing machine with sluicing programme has been provided in the laundry. However, there are still a number of areas, which needs addressing. For example, the recommendations contained in the Fire Safety Officer’s inspection The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 16 report dated 15 of November 2004 are still not fully implemented; the car park is still to be resurfaced and exterior of the premises still remains to be repainted. The home has not yet undertaken a risk assessment in all of the premises and facilities by suitably qualified persons including an Occupational Therapist. The Registered Providers need to provide storage areas for aids and equipment, including wheelchairs. The bathrooms on both floors were in need of urgent repair and/or replacement. The damaged floor covering in the kitchen is in need of replacement, and a thermostat is to be fitted to the hot water outlet used by the cook. Suitable tables and lockable facility in a number of bedrooms must be provided. The radiators in all the remaining bedrooms and entrance hall are still to be covered appropriately. Window to bedroom 11 need to be repainted. The hot water temperature in all the hot water outlets must be maintained at the required level of 43 degree C at all times and it was noted that last hot water temperature test was recorded on 31.March 2005. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 17 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, 29 and 30 The home is staffed to a level that ensures the service users’ needs are met at all times. The home continues to support staff to complete training. EVIDENCE: The information provided by the home and the available staff rotas showed that the home is adequately staffed. It was noted from the staff recruitment records that the home does obtain on new staff two relevant references and also carry out the CRB checks. The training records provided by the Acting Care Manager does not provide the accurate information on what training and who completed which courses and when. The Acting Care Manager stated that the TOPSS Induction and Foundation training is being introduced for new members of staff. The home needs to maintain accurate and up to date training records for all staff employed at the home and made available for inspection. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 18 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) 31, 33 ,35, 36 and 38 The home is managed efficiently but urgent attention to be given to formalising the position of the Acting Care Manager. The staff are clear about their roles and responsibilities. Good systems of communication are in place to seek the views of the service users and their families/friends. The service users’ money is being appropriately handled by the Acting Care Manager. There is staff supervision system in place. Health, safety and welfare of service users and staff are promoted by safe working systems put in place by the Acting Care Manager and staff. EVIDENCE: It was noted that the care home has been without a Registered Manager since the end of April 2004. However, the Registered Providers have appointed an acting care manager, but to date an application of registration has not been received. The Commission is concerned with lack of progress in this matter. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 19 The Registered Providers need to take urgent action to bring forward an application of registration for the Manager at The Elms. The acting care manager stated that the home as yet does not have any formal Quality Assurance systems in place and that she will establish a system in order to comply with this Standard as soon as possible. Monies held at the home on behalf of the service users are handled in line with the home’s policy of handling service users’ money. A sample was checked and found to be satisfactory at the inspection visit. It was stated by the acting care manager that she is not up to date with the required formal supervision meetings with all the staff. During the Inspector’s meeting with the staff, they also confirmed that they have not received regular supervision at the required intervals. Accident and fire prevention records examined which were appropriately maintained. Matters pertaining to fire safety and environmental health were found not to be fully satisfactory and all the outstanding issues from the previous still to be appropriately addressed. However, it was noted that the home has not yet completed the risk assessments on the premises and facilities, and the staff still have to complete their safe working practice topics training and updates in order to comply with the TOPSS specifications and standards. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 20 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 2 x 3 x 3 x 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 x 15 3 COMPLAINTS AND PROTECTION 1 x 2 2 x 2 2 x STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 1 x 1 x 3 2 x 1 The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 21 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 OP1 Regulation 4 (1)(2) Requirement The Registered Providers must provide the revised,updated and finalised Statement of Purpose for the home. The Registered Providers must provide an updated and revised Service Users Guide and in relevant language and suitable format, including in large letters for the intended residents. The Registered Providers must ensure that all members of care staff receive accredited medication training in accordance with NMS 9.7. The Registered Providers must ensure that the outstanding recommendations contained in the Environmental health Officer inspection report dated 31 October 2003 and the outstanding recommendations in the Fire Safety Officers inspection report dated 15 November 2004 are addressed as a matter of priority; and the car park area is resurfaced, and the exterior of the premises is repainted, and the damaged floor covering in the kitchen is appropriately replaced, the Timescale for action Completed 2. OP1 5 (1) (2( Completed 3. OP9 13 31/12/05 4. OP19 23 31/10/05 The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 22 5. OP21 23 6. OP22 23 7. 8. OP24 OP25 16 and 23 13 9. OP30 12 10. OP 31 9 11. OP33 24 window to bedroom 11 must be repainted. The Registered Providers must ensure that bathrooms on both floors muat be appropriately repaired/replaced The Registered Providers must ensure that an assessment of the premises and facilities are made by suitably qualified persons, including a qualified Occupational Therapist; and storage areas are provided for aids and equipment, including wheelchairs. The Registered Providers must provide suitable lockable facility and tables in all the bedrooms. The Registered Providers must ensure that suitable covers are provided for all the radiators in the home and the hot water temperature in all the hot water outlets must be maintained at the required level of 43 degreesC at all the times and all the tests records maintained up to date; and a suitable thermostat must be fitted to the hot water outlet in the kitchen. The Registered Providers must ensure that all new staff receive Induction and Foundation training which meets the National Training Organisations specifications and standards and the home must keep an up to date record of all training received by all the members of staff. The Registered Providers must ensure that an application of registration for the care manager of the home is brought forward as a matter of urgency The Registered Providers must ensure that the home has an effective system of Quality 30/09/05 Completed 31/08/05 30/09/05 30/09/05 Completed 30/09/05 The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 23 12. OP36 18 13. OP38 4,12, 13,17and 23 Assurance based on the outcomes for service users in which standards and indicators to be achieved are clearly defined and regularly monitored; and an annual Quality Assurance development plan is produced from the findings. The Registered Providers must 31/12/05 ensure that all staff receive their formal supervision at least six times a year and all records approriately maintained. The Registered Providers must 15/09/05 ensure that Risk Assessments are carried out for all safe working practice topics and that significant findings of risk assessments must be recorded and appropriately implemented. All new staff must receive induction and foundation training and updates to meet the TOPSS specifications on all safe working practice topics; and that hot water outlets are tested at least once a week and appropriate records maintained at all times and suitable action taken; certificates of maintenance of the fire alarm system,emergency lighting system and electrical system and equipment are made available in the home and for inspection ; and that Fire Risk Assessments must also be undertaken as a matter of priority; and that those members of staff who have not yet received training in moving and handling, fire safety, first aid, food hygiene, health and safety and infection control. 14. 15. The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 24 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 Good Practice Recommendations The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 2nd Floor, St Davids Court Union Street WOLVERHAMPTON WV1 3JE 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 The Elms E56 E01 000020887 The Elms V222728 UI 270405 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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. 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