Inspection on 07/02/06 for

This inspection was carried out on 7th February 2006.

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 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

03/08/07

27/03/07

04/07/06

19/09/05

28/02/05

05/07/04

22/10/03

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

CARE HOMES FOR OLDER PEOPLE The Elms Verwood Road Elmhurst Aylesbury Bucks HP20 2AY Lead Inspector Christine Sidwell Unannounced Inspection 7th February 2006 01:30 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 DS0000023063.V282811.R01.S.doc Version 5.1 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 DS0000023063.V282811.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Elms Address Verwood Road Elmhurst Aylesbury Bucks HP20 2AY 01296 489530 01296 337991 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) admin@fremantletrust.org The Fremantle Trust Mrs Susan Ann Norton Care Home 56 Category(ies) of Dementia (16), Old age, not falling within any registration, with number other category (40) of places The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the Home also provides care to the following categories of Service Users under the category `Older People` 1 (One) Service User on respite care who has Dementia 6 (Six) Service Users who have learning difficulties 1 (One) Service User who may have Mental Health Issues. 19th September 2005 Date of last inspection Brief Description of the Service: The Elms is a care home providing personal care and accommodation for fiftysix frail older people. The home is owned by the Fremantle Trust, which is a not for profit charity. It is situated in a residential area of Aylesbury, close to the facilities that a large town can offer. It was purpose built in the early 1970s and has fifty-four single bedrooms and one double bedroom. It is divided into five smaller units, each of which has a lounge and dining area. One thirteen bedded unit provides specialist care for people with dementia. There is a passenger lift. There are pleasant gardens and outdoor sitting areas. The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection undertaken on the 7th February 2006. The purpose of the inspection was to inspect the remaining key standards, which were not assessed at the previous inspection, and to assess compliance with the requirements arising from that inspection. Policies and procedures were examined. The deputy manager was interviewed. A short tour of the building was undertaken and a number of residents and care staff were spoken to. This report should be read in conjunction with the previous report. What the service does well: What has improved since the last inspection? What they could do better: The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 6 All care plans should be reviewed on a monthly basis by the unit care coordinators to ensure that they are up-to date and reflect service users current needs. Those residents who are sponsored by their local authorities should have an annual review of their care with their care manager. All staff who administer medication should have medication administration training. Although a refurbishment programme is in place, seven rooms still did not have basic equipment such as towel rails. This must be addressed. Not all beds have been replaced yet, although some new beds have been purchased. A rolling programme to replace the old divan beds, particularly those with ill fitting or no headboards, must be agreed. Whilst health and safety policies and procedures are in place, it was not clear that all staff had had the mandatory basic training in manual handling, fire awareness, food hygiene, medication administration and infection control. The training matrix must be updated and the manager must ensure that all staff have the basic mandatory training. The staffing levels must continued to be monitored to ensure that resident’s needs can be met. The numbers of staff holding or working towards National Vocational Qualifications in Care must be increased if staff are to have the knowledge and skills to meet resident’s needs. The programme, which has already started, to implement formal supervision must be rolled out to all staff. Asking residents, families and other professionals their views of the home, and developing action plans to address these, would enhance the quality assurance systems. 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 DS0000023063.V282811.R01.S.doc Version 5.1 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 DS0000023063.V282811.R01.S.doc Version 5.1 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): These standards were not assessed at this inspection. The key standards were met or not applicable at the last inspection, undertaken on the 19th September 2006. EVIDENCE: The Elms DS0000023063.V282811.R01.S.doc Version 5.1 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 and 9 There is continued improvement in compliance with these standards, although they are not yet fully met and not all residents have had their care needs reviewed on a regular basis by the home or their care manager, to ensure that their needs are being met. Not all staff who administer medication have had formal training and resident’s medication needs may not be met safely. EVIDENCE: At the last inspection a requirement was made that that unit care coordinator review service user’s care plans on a monthly basis. This has now been implemented on three of the units and plans are in hand to ensure that they are reviewed on the remaining units shortly. The care plans seen showed an improvement and contained evidence that the unit co-ordinators had reviewed them within the last month. Although good progress has been made, the requirement will be repeated in this report and a new timescale will be set, until the process is consolidated throughout the home. Four care plans were selected at random and examined. They all contained evidence that the resident’s risk of falls had been assessed. The deputy manager said that those who required them, and who wished to wear them, wore hip protectors. The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 10 Not all residents have been reviewed by their care manager during the last year although it was clear that some had. The deputy manager agreed to compile a list for all residents, the date that they were last reviewed and arrange for reviews of those residents who had not been reviewed during the last year. An additional visit will be made in March 2006 to ensure that this process has been started. The deputy manager said that staff have had medication training offered by the pharmaceutical company which provide medication. One of these companies provides accredited training. It was not evident from the training matrix that all staff who administer medication have had medication training however. The staff who were administering medication on the day of the inspection had had training and the deputy manager felt that all staff would have had the required training. The deputy manager has agreed to update the training matrix to identify those who administer medication and to enter the date when they had that training, and to ensure that carers who have not had the required training do not administer medication. The Elms DS0000023063.V282811.R01.S.doc Version 5.1 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): These standards were not assessed at this inspection. The key standards were met at the last inspection undertaken on the 19th September 2006. EVIDENCE: The Elms DS0000023063.V282811.R01.S.doc Version 5.1 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 and 18 The complaints and protection of vulnerable people policies and procedures are in place and generally work well giving residents and their families the opportunity to resolve issues of concern. EVIDENCE: There is a complaints procedure and policy. A record of complaints is held. The organisation has received a complaint about the care of a resident and although prompt action was taken to address the issues of care that the complainant raised she was not reassured by the conduct of the investigation. The Commission for Social Care Inspection has agreed to look into this complaint. The residents spoken to said that they were happy at the home and that they knew who to raise concerns with. The staff were aware of the home’s policies on the protection of vulnerable adults. There is a protection of vulnerable people policy and whistle-blowing policy. The protection of vulnerable people policy makes reference to the local multi-agency strategy although the home did not have a copy. They are asked to obtain one. A number of strategy meetings have been held during the last year and the organisation has drawn up action plans to address deficits identified. The Elms DS0000023063.V282811.R01.S.doc Version 5.1 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): 24 and 26 The refurbishment and repairs programme, although not yet complete, is gradually providing residents with a better standard of accommodation in which to live. Infection control policies and procedures are in place and should protect residents from acquired infection. EVIDENCE: The maintenance programme has been continued and most resident’s rooms have now been refurbished. Seven rooms however still had broken or missing towel rails and this must be addressed. The deputy manager is undertaking a monthly check of the premises and has gradually addressed many of the outstanding repairs. Residents had personalised their rooms with their own pieces of furniture and belongings and staff obviously encourage them to do so. The inspector was told that door locks, which can be opened from the outside in an emergency, are to be fitted shortly. Security locks have been fitted to both units on the ground floor. A number of new beds have been purchased as have a number of new commodes, (the rooms are not ensuite). Not all divan beds had headboards and some of these appeared not to fit the The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 14 bed. The refurbishment programme should be completed and the elderly divan beds be replaced. There is an infection control policy and procedure. The laundry is situated away from the kitchens and has impermeable floors. The washing machines have the capacity to wash at a minimum of 65°C. Hand washing facilities are available although not all resident’s rooms had wall mounted liquid soap and paper hand towels for staff. This should be considered. The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30. The staffing levels must continued to be monitored to ensure that resident’s needs can be met. The numbers of staff holding or working towards National Vocational Qualifications in Care must be increased if staff are to have the knowledge and skills to meet resident’s needs. EVIDENCE: The overall staffing numbers meet the recommendations set by the Department of Health. The night staffing levels comprise three carers and one senior carer. The deputy manager said that they were working as a team although the size and layout of the home is such that they work in pairs on each floor. This does mean that residents may not be supervised if both carers are with one resident. The night staffing levels must be continued to be monitored carefully and increased if residents needs increase. In particular the needs of those with dementia on the ground floor should be monitored carefully and the overall night staffing levels be increased if necessary. The night staff are also expected to undertake laundry and housekeeping duties. This should also be reviewed as clearly these duties may take them away from providing care. The Fremantle Trust is an accredited provider of National Vocational Qualifications. Seven of the fifty-eight carers and relief carers hold the National Vocational Qualification in Care at Level 2 or above, twelve percent. A further eleven are working towards the award. The home does not meet the standard that fifty percent of carers will achieve this by 2005, nor will it be met The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 16 when the current staff who are working towards achieving the award, complete it. It is a requirement of this report that an achievable plan to achieve this is developed and agreed by the Fremantle senior management team. Fremantle Trust has a training matrix which when completed shows whether all staff have the required basic mandatory training with annual updates. The home is using this. At present the matrix suggests that 12 members of staff have not had basic manual handling training nor an annual update although concerns were expressed that the matrix may not be up to date. Not all staff have had food hygiene training nor fire awareness training in the last year. The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 17 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): 31, 33, 36 and 38 There is an experienced manager who is knowledgeable about the needs of the elderly. Quality assurance systems are in place although they could be enhanced by a systematic approach, using surveys and other methods, to seek the views of service users, their families and other professionals visiting the home and developing action plans to address issues that are raised. A programme to implement formal staff supervision has been commenced and should be rolled out to all staff to ensure that they have the support necessary to meet resident’s needs. EVIDENCE: The home has an experienced manager who is registered with The Commission for Social Care Inspection. She is working towards the National Vocational Qualifications in Management and Care at Level 4. She is only responsible for one home. The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 18 There is an annual development plan for the home. Staff and resident and family meetings are held regularly. An Age Concern advocate visits the home on a regular basis. A resident and family satisfaction survey has not been undertaken during the last year. A representative of the organisation visits the home regularly and submits reports to The Commission for Social Care Inspection on a regular basis. Action is taken in response to requirements from inspections, although it can take time for actions to be fully consolidated. The deputy manager said that a staff supervision programme had been commenced with the senior staff and would be rolled out to all carers shortly. There are Health and Safety policies and procedures in place. However it was not clear that all staff had had the required mandatory training. Fremantle Trust has a training matrix which when completed shows whether all staff have the required basic mandatory training in manual handling, food hygiene, fire awareness, medication administration and infection control, with annual updates. The home is using this. At present the matrix suggests that 12 members of staff have not had basic manual handling training nor an annual update although concerns were expressed that the matrix may not be up to date. Not all staff have had food hygiene, fire awareness or infection control training in the last year. It is a requirement of this report that the training matrix is updated and that all staff have manual handling, fire awareness and, food hygiene training. The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 19 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 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 x x x x x 2 x 3 STAFFING Standard No Score 27 2 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x 2 x 2 The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 20 No 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 OP7 Regulation 15 Requirement All residents must have their care plans reviewed by the unit care co-ordinator on a monthly basis, to ensure that they contain the correct documentation, are complete and have been updated to describe the residents current care needs. This is an unmet requirement of previous reports and a new timescale has been set. All residents must have their care plan reviewed by their care manager on an annual basis. This is an unmet requirement of previous reports and a new timescale has been set. All staff who administer medication should have medication training from an accredited source. The repairs to the remaining rooms must be completed. This is an unmet requirement of the previous report and a new timescale has been set. Locks which can be opened from the outside should be fitted to DS0000023063.V282811.R01.S.doc Timescale for action 31/03/06 2 OP7 15 30/06/06 3 OP9 13 31/03/06 4 OP25 13 31/03/06 5 OP24 23 31/03/06 The Elms Version 5.1 Page 21 6 OP27 18 7 OP28 18 8 OP30 18 9 OP33 24 10 OP36 18 11 OP38 13 12 OP38 13 13 OP38 23 residents the doors where they wish to keep their door locked. The night staffing levels must be kept under review and increased if the dependency of residents increases. A programme to enable 50 of staff to achieve the National Vocational Qualifications in Care at Level 2 or above must be implemented. All staff must have mandatory training with annual updates. This is an unmet requirement of the previous report and a new timescale has been set. An annual; survey of the views of residents, their families and other professionals using the home should be undertaken and action plans developed to address any issues that are raised. All staff should have the opportunity of formal supervision every two months. This is an unmet requirement of previous reports and a new timescale has been set All new staff must have manual handling training and all existing staff annual updates. This is an unmet requirement of previous reports and a new timescale has been set. All staff who handle food must have food handling training. This is an unmet requirement of previous reports and a new timescale has been set. The night staff must have fire training and annual updates. This is an unmet requirement of previous reports and a new timescale has been set. 30/06/06 30/06/06 30/04/06 30/09/06 30/04/06 30/04/06 30/04/06 31/03/06 The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 22 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 OP26 Good Practice Recommendations The organisation should consider installing wall mounted soap dispensers and paper hand towels in residents rooms. The Elms DS0000023063.V282811.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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