Inspection on 20/10/08 for The Elms Nursing Home

This inspection was carried out on 20th October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Elms Nursing Home 25/10/07

The Elms Nursing Home 22/06/06

The Elms Nursing Home 25/07/05

The Elms Nursing Home 25/04/05

The Elms Nursing Home 01/09/04

The Elms Nursing Home 09/06/04

Similar services:

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Elms Nursing Home The Whitepost Health Care Centre Ranelagh Road Redhill Surrey RH1 6YY     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Marion Weller     Date: 2 0 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 35 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 35 Information about the care home Name of care home: Address: The Elms Nursing Home Ranelagh Road The Whitepost Health Care Centre Redhill Surrey RH1 6YY 01737764664 01737780710 michaelfaulkner@whiteposthealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Michael Faulkner Type of registration: Number of places registered: Dr P J David,Mrs S P David care home 49 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users to be accommodated is 49. The registered person may provide the following category of service only: Care home nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) Dementia - (DE) Physical disability - (PD) Date of last inspection Brief description of the care home The Elms is a registered care home providing nursing care for up to 49 residents. The home can accommodate up to 44 older people (over 65 years) and 5 younger adults from 40-65 years. The home is situated on the site of the old East Surrey Hospital at the top of Whitepost Hill and is on the same site as another home separated from The Care Homes for Older People Page 4 of 35 49 0 49 Over 65 0 49 0 Brief description of the care home Elms by internal doors. The home is within walking distance of Redhill, which provides access to shops, public transport and a range of social and leisure facilities. The home has a large garden to the rear of the premises. All floors that accommodate service users are accessible by a lift. The Elms is privately owned and run by the Whitepost Health Care Group who run other similar establishments. There are parking facilities to the front of the premises. The weekly fees are from #454 -#700 per week. Care Homes for Older People Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last inspection of this service was completed on 25th October 2007. This key unannounced inspection was conducted by Marion Weller, Regulatory Inspector who was in The Elms Nursing Home on the 20th October 2008 from 10:20 am until 5:30 pm. During that time the inspector spoke with some residents and some members of staff. The owner/ provider, the registered manager, the estates manager and a representative from the organisations Personnel Department. Parts of the home and some records and documents were inspected and care practices were observed. Medication administration practices were also inspected on this visit. A number of survey forms were received prior to the inspection and a telephone interview was conducted with a residents relative after the site visit had concluded. Care Homes for Older People Page 6 of 35 The inspection report also takes into account all the information obtained about the home since the previous site visit. This includes formal notifications, phone calls, letters received and any complaints or allegations notified. The manager was asked to complete the homes Annual Quality Assurance Assessment (AQAA) prior to the inspection. This document was returned within the timescale given. Survey respondents said they were generally satisfied with the care provided and staff were hard working. A number of surveys however raised concerns about staffing levels which they felt were inadequate at times and language and cultural barriers between staff and residents. Survey forms included the comments: ..Staff very good when they have time. ..Staff are usually helpful. And ..Resident privacy is respected. Some other statements made by survey respondents are included in the text of the report. No complaints have been made directly to the Commission about this home since our last inspection. There have been three adult protection alerts raised that have been referred to Social Services Safeguarding Adults Department. The home cooperated fully throughout investigations. At the time of writing this report there were no outstanding complaints about this service held by the Commission. The registered manager and the staff gave their full cooperation and help throughout the inspection. What the care home does well: What has improved since the last inspection? What they could do better: The homes information documents require further review and development to ensure people accessing the service have all the information they need prior to moving in and later to use as reference. Care Homes for Older People Page 8 of 35 The arrangements for contacting the service by telephone or in person should be reviewed to ensure they are suitably responsive and meet peoples needs. Language and cultural barriers between staff and service users must be overcome to ensure peoples choices; needs and preferences are consistently understood and complied with. Despite significant improvements residents would benefit still further from care documentation and care planning systems being further improved. The storage of topical medicines must be improved in line with good practice demands to secure residents safety and welfare. Current staffing levels do not demonstrate that residents care needs are being met at all times and must be reviewed. Some working practices require further development to ensure the safety and welfare of service users is consistently promoted and protected. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 35 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can be confident that their needs would be assessed prior to a place at the home being offered. The Homes information documents require further review and development to ensure people accessing this service have all the information they need prior to moving in and later for reference. The arrangements for contacting the service by telephone and for receiving visitors in person should be reviewed to ensure they are designed to be suitably responsive and meet individual need. Language and cultural barriers between staff and service users must be overcome to ensure peoples choices,needs and preferences are consistently understood and complied with. Care Homes for Older People Page 11 of 35 Evidence: The homes statement of purpose is available for visitors to see. The document has recently been updated. The copy sent to the CSCI by the manager requires some minor amendments to ensure it complies fully with the demands of regulation. Consideration should also be given to making the content more user friendly for the client group accommodated at The Elms. For instance, the last paragraph of the managers introduction uses medical terminology and is overly complex. This would benefit from review to ensure people of all capacities can understand it. The statement of purpose is not dated; neither does it have a review date. This makes it unclear for service users if the document is the most up to date copy. The contact details for the provider organisation needs to be made clear in the document for people who need that information. The attached complaints procedure would benefit from the inclusion of the most up to date contact details for the CSCI and the contact details of the local social services and health care authorities. Social services hold statutory powers to investigate complaints and safeguarding issues raised with them about registered homes. The inclusion of this information would ensure people are not confused or delayed in accessing guidance and help with issues of concern. The home provided us with their annual quality assurance assessment (AQAA) before this site visit. The AQAA is a written self-assessment that focuses on how well outcomes are being met for people using the service and also provides us with some numerical information. The manager records that the home advertises the services they offer on a website and is also intending to produce up to date brochures for prospective residents and their families. The brochures were not available to see on the day of the site visit. The manager said the brochures were currently with the printers. The manager recognised that the homes printed information could be improved upon. The manager visits prospective residents prior to admission to make a decision as to whether the home can meet the persons needs. Information is obtained from other parties, including relevant health care professionals to assist in assessment decisions. Two pre admission assessments were inspected in the service user standex files and were found to be sufficiently detailed and comprehensive. The manager said he encourages prospective residents and their relatives or representatives to visit the home prior to any firm decision being made to move in. Staff evidenced they had the clinical knowledge and practical skills to care for individuals admitted to the home and were observed to be very hard working. There were however numerous concerns raised with the inspector about the inability of some staff to communicate effectively with service users and to understand their cultural needs and preferences. The home predominately relies on staff recruited from abroad whose first language is not English. Some of these staff have not yet had sufficient Care Homes for Older People Page 12 of 35 Evidence: time and opportunity to develop their spoken English or their cultural understanding of the country. The homes AQAA records that the client group accommodated is predominately white/ British. One survey respondent said, ...I feel that in some cases residents have a problem understanding the dialect of some staff and tend to get very frustrated as a result. One resident spoken with said, ...Sometimes it is very difficult to understand the staff and sometimes they dont understand me either. The AQAA further records that there has been a lack of recruitment of local staff, which the manager feels has been a barrier to improvement in the last 12 months. He states, ..there is currently a heavy reliance on staff needing visas and work permits. The manager has tried to reduce the impact of these barriers by advertising for staff on a wider scale and in different mediums. The manager records, ..we are trying to recruit more British people, as this better meets the cultural needs of our (resident) population. The AQAA records that over the next 12 months the home plans to consolidate and further develop sound links with the public, relatives and the people buying their services, such as care managers. To this end, the manager may need to review how people access The Elms and give consideration to their welcome and the homes response to enquiries on the telephone. The reception area to the home is currently unmanned. On the day of the site visit the inspector rang the doorbell three times and experienced a ten-minute wait to gain access via the homes main entrance. When asked to comment on how the service could improve, one survey correspondent said, ...Sometimes they are very slow to respond to the door bell and improvements could also be made to the manner in which staff, besides the manager, deal with enquiries by telephone. The manager records in the homes AQAA, ...Staff have improved in answering the door bell and the telephone. This was not wholly evidenced on the day of the inspection. Intermediate Care is not provided at The Elms. Care Homes for Older People Page 13 of 35 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has made significant improvements but residents would benefit further from care documentation and care planning systems being improved. The storage of medicines must be addressed in line with good practice demands to secure residents safety and welfare. Current staffing levels do not demonstrate that residents personal care needs are being met at all times Evidence: All residents have a care plan. Three care plans were looked at in detail. The home uses a Standex system for care planning. All care plans contained sufficient detail about the individuals needs and aspirations and provided clear direction for staff to follow. Risk Assessments were in place and provided guidance in minimising identified risks. Care plans evidenced regular review. The requirement issued at the last inspection to ensure care plans and risk assessments were reviewed has been complied with and will be removed from this report. Changes made to care plans as a result of the monthly review were being recorded. The visits and outcome of health professionals consultations with residents were being recorded, signed and dated. Care Homes for Older People Page 14 of 35 Evidence: Documentation seen also confirmed that residents had access to a GP and visits from other health professionals are arranged and enabled as necessary. Residents daily records were being maintained. The amount of detail in records was found to be inconsistent and dependent on the staff member completing the record. Evidence was seen of entries that recorded, ..all care given.. which is not helpful or adequate and should be avoided. Daily records when well written help senior staff to audit the care provided and ensure that staff follow the guidelines in the care plan. It is in the homes interests to be able to illustrate what they have done for a resident and provides evidence on which to base reviews and to record that they are following the assessment of a residents needs. A recommendation for current practice to be reviewed will be made in this report. Evidence was seen that where possible residents and relatives are involved in drawing up their care plans and they are consulted in reviewing and amending the documents as capacity allows. Some care plans were signed as evidence of the persons involvement in drawing up the plan and their agreement to it. However, this was not the case for all care plans viewed. The standex system is by design a fragmented, repetitive and unwieldy format and can make the retrieval of information difficult and time consuming at audit. For this reason it is difficult to see how current arrangements evidence that care plans are provided in a style and format which is easily accessible to residents and their relatives, as regulation demands. The manager spoke of his intention to review the care planning format. Only Registered Nurses administer medication to the residents. There are currently no residents who self medicate in the home. In line with a requirement awarded at the last inspection, the manager records in the AQAA that all policies associated with medication administration have been redrafted and there has been a significant improvement in practice. Regular independent audits are now completed by the homes dispensing pharmacist. An audit of medication administration practices and records, undertaken during the site visit largely evidenced safe practice. The only exception being that residents prescribed topical medicines are not being stored correctly after use. It was clearly evidenced that normal practice is for them to be left in residents bedrooms for the ease of staff and they are clearly on view from the corridor. Due to the mental health needs of some service users accommodated and their associated behaviors, this is unsafe. The manager stated his intention to remedy this shortfall to ensure they are fully compliant. A key worker and named nurse system are used in the home. Residents are informed of the names of staff who can be expected to have a special, but not exclusive relationship with them. Evidence was seen in two residents bedrooms of signage which Care Homes for Older People Page 15 of 35 Evidence: provided this information. Signs viewed however gave the name of a nurse who had left the homes employment some months previously. This clearly evidences a lack of attention to detail which results in confusion for the individual and their relatives and frustrates and disappoints peoples expectations of the service. The manager undertook to address this. The inspector had the opportunity to speak with three residents privately in their bedrooms and a residents relative on the telephone after the site visit ended. People generally expressed satisfaction with the care offered and mentioned that staff worked hard. They felt that the majority of staff treated them with dignity and respect. They raised concerns however about insufficient staffing levels, which resulted in a lack of responsiveness to their needs. In addition, there were language and communication problems experienced with some staff. One survey respondent from a local commissioning team records, ..Some service users have spoken of feeling very rushed regarding personal care. Another professional records, ..Had some issues with regard to care during the night, eg - people waiting a long time for toileting etc. Individuals wishes for the end of life are recorded on care plans. Some individuals and their relatives have made a specific request about their wishes in the event of requiring resuscitation. The manager was advised that those involved in this important decision should be clearly documented in the individuals care plan and decisions taken for those who lack capacity, must be recorded in line with the demands of The Mental Capacity Act 2005. Decisions made must be kept under regular review. The manager was advised to consult the NHS End of Life Care Programme which is available on the Department of Healths website for further guidance. This provides examples of innovative practice for care homes to follow. Care Homes for Older People Page 16 of 35 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Routines of daily living and the activities being made available are not consistently meeting residents expectations or needs. Evidence: Residents are consulted about their social interests and needs as part of the homes initial pre admission assessment. Social needs are recorded on individual care plans together with likes and dislikes. The manager said that residents religious and cultural needs are catered for. One bedfast resident raised concerns during the inspection that they had not been enabled to speak with their priest recently. They were dependent on staff telephoning and staff were said to be too busy. This was fed back to the manager to investigate and resolve with the individual. The manager confirmed in discussion that representatives of various religious denominations visit the home regularly from local churches and Holy Communion can also be arranged. The homes AQQA records that people are enabled to visit local places of worship, if they request this. It is normal practice for a programme of activities to be arranged, which the homes 3 activities coordinators lead. However, since the last inspection two of the activities coordinators have left the homes employment. The manager has successfully Care Homes for Older People Page 17 of 35 Evidence: recruited to some of the vacant hours and stated that the successful applicant was to start work soon. The one remaining activities coordinator, due on duty on the day of the site visit was unwell and unable to attend. One of the care staff had also informed the home they were unwell and unable to work that morning. The homes staffing compliment was therefore reduced, with no bank staff available to cover the vacant hours. The manager stated that unfortunately no formal activities were therefore to be arranged for that day. Visitors are welcome at anytime and facilities are available for them to access drinks or a meal. Residents are free to entertain visitors in the homes communal areas on their individual units or in their bedrooms. Residents spoken with confirmed that they mainly entertained guests in their bedrooms. The homes AQAA records that of the 34 residents accommodated at the time of completion, 17 residents were bedfast with a further 14 people wheelchair fast. Only 3 people were capable of walking for short distances. Diagnostically every resident had a degree of organic dementia and mental health problems and/or physical disability. This home is now a high dependency environment. It is therefore difficult to judge how such an environment can meet residents lifestyle expectations and preferences, without current staffing levels being reviewed to take increasing demands into consideration. A requirement will be made to this effect. During a telephone interview with a relative undertaken after the inspection, they raised concerns that there was not enough staff at times to cover all areas of the home, which in their opinion left people at risk. Similar issues of concern had been documented in relatives meetings. Relatives meetings are held four times a year. Notes of the most recent meeting dated August 2008 were viewed on this visit. One entry states, ..Concern and anger was expressed by all present at the level of staffing and lack of supervision of residents left alone in York lounge, one relative reporting an absence of staff lasting 45 minutes. The interviewee stated that the situation had improved recently. The homes AQAA records that residents in communal areas are checked on every 15 minutes if workload occupies staff elsewhere. The menu seen is tailored to the needs of individuals and offers choice. The AQAA records that as a result of listening to resident feedback, menus in future will offer more traditional British Food. One survey respondent said, ..Alternatives are available when I dont like the dish offered on the menu. Relatives meeting notes record their compliments to the kitchen on the standard of food provided for residents. Those people that need support with their meals have this identified on their care plan. One professional survey respondent said that on occasions they had needed to draw attention to the nutritional needs and/or appropriate diet for their clients with the manager. In particular there were concerns about people who could not feed Care Homes for Older People Page 18 of 35 Evidence: themselves. It should be noted that the respondents concerns are around the time that staff have to help and support people who may need to be fed and not with the standard of food provided or its nutritional content. Care Homes for Older People Page 19 of 35 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to ensure residents are protected from abuse and they can be confident that their concerns and complaints will be acted upon. Evidence: The service has strategies in place to ensure that those who live in the home and those who visit can make their views and complaints known. The homes AQAA records that they have received 2 formal complaints since the last inspection. Issues raised have been investigated and outcomes reported on within the timescale given in the homes complaints procedure. The homes complaints procedure would benefit from minor amendment as detailed in the Choice of Home outcome area to ensure it complies fully with regulation and provides people with all the information they need. A recommendation will be made to this effect. The manager has awareness that the quality of the service provided is the responsibility of the provider and concerns and complaints should be raised with the home in the first instance. Residents spoken with knew who to complain to and said they would feel comfortable doing so. Regular relatives meeting are held and the manager does his best to see each resident and speak with them daily. This was evidenced in conversation with residents. The CSCI is aware of three Adult Protection alerts and subsequent investigations that Care Homes for Older People Page 20 of 35 Evidence: the home has been involved in since the last inspection. The provider and manager approach investigations with openness, honesty and a willingness to help and act immediately on any outcomes and action plans decided to secure residents welfare. One professional survey respondent said when asked to comment on what the home does well, ..The manager communicates promptly any issues or concerns regarding the welfare of service users. Most staff have attended training in safeguarding vulnerable adults and update sessions are planned on a rolling programme. There is a procedure for the protection of vulnerable adults and a procedure for staff to ..whistle blow.. - Staff are made aware of both procedures during their induction. Criminal Record Bureau checks have been obtained for all staff. The registered Manager is aware of his obligations with regard to ensuring the safety of residents and protecting them from abuse. Care Homes for Older People Page 21 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have a clean and comfortable environment in which to live. They will benefit further from work that is now underway to improve the homes bathroom facilities. Evidence: The Elms was originally a cottage hospital and internally the property still resembles this layout and style. It is a matter of conjecture whether this type of layout could be described as ..homely.. - No survey respondents or people spoken with however raised any issues about the homes environment and therefore for the purposes of this report it is accepted that it is currently meeting peoples individual and collective needs satisfactorily. Resident accommodation and communal areas are laid out over three floors which can be accessed by a passenger lift and stairs. There are rear gardens that appear well maintained and can be accessed by residents and visitors as they wish. The provider has recently reviewed the viability of the homes double bedrooms and these are now offered for single occupancy, which means each resident in the home has their own room. The manager advised that one large bedroom would continue to provide shared accommodation for couples, should the demand exist. Care Homes for Older People Page 22 of 35 Evidence: Some areas in the home have been decorated and refurbished during the last year. The manager advised that there is an ongoing maintenance and refurbishment programme. Some furniture on the the top floor unit was seen to be aged, but furniture and soft furnishings in refurbished areas are generally of good quality. The homes AQQA records that the provider has plans to focus on total service redevelopment. Some environmental issues were discussed with the manager during a tour of the building. For example, the geography of the building means there are long corridors with numerous rooms leading off. It was a disorientating experience for the inspector, so it would be easy for residents who lack capacity to lose their bearings. The environment also lacks interest for clients with dementia in some other areas. In addition the geography of the building and the lay out of the accommodation over three separate floors has a significant impact on the numbers of staff required to effectively manage and provide for the specialist and high dependency care that the home states it offers. As a result of a requirement issued at the last inspection to provide the Commission with details of how the homes existing bathroom facilities effectively met the diverse needs of the people being accommodated. The provider arranged for a professional assessment and report, which resulted in a plan of action to improve and upgrade the facilities and provide for two new bathrooms in the home. One bathroom that would effectively be a wet room and the other would provide for a specialist profiling bath to be installed. There has been some slight delay in the work starting due to structural building difficulties but it was clearly evidenced that work has commenced. The provider is confident that the project will be completed by the end of October 2008. As part of the project some much needed additional storage space is also to be provided. Currently some items of the homes equipment are being stored in residents communal bathrooms. Equipment seen was of a good standard and regularly serviced. The home has a large supply of transfer slings for hoists but many were hanging together and are not maintained for named individuals. Best practice demands that hoist slings are maintained for individual residents to evidence the homes adherence to good infection control measures. It will be recommended that the manager seek expert advice from the local Health Protection Agency. The home was being kept clean, hygienic and was free from any offensive odours and apart from the communally used hoist slings, systems were in place to control the spread of infection. Care Homes for Older People Page 23 of 35 Care Homes for Older People Page 24 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Current staffing levels do not demonstrate that residents needs are being consistently met at all times. Specific staff training and support strategies must be in place to overcome language and cultural barriers between some staff recruited from overseas and residents accommodated to ensure they have their choices, needs and preferences understood and complied with. Evidence: The home is divided into three separate service units with resident accommodation arranged over three floors. On the day of the site visit there were 35 residents accommodated. The home is registered to provide 49 beds in total. The staffing level confirmed by the manager was, 2 nurses on duty during the day time. To assist them, 6 health care assistants on duty during the morning shift and 5 health care assistants deployed on the afternoon/ evening shift. At night there is 1 nurse deployed to all three floors. Health care assistants deployed are meant to number 3 staff. The manager however said he currently deploys 4 staff to address safety and resident dependency considerations during night hours. Ancillary staff are also employed during day hours to undertake domestic, catering, maintenance and administrative duties. Care Homes for Older People Page 25 of 35 Evidence: The manager records in the homes AQAA, ...that of the 34 residents accommodated at the time of completion,17 residents were bedfast with a further 14 people wheelchair fast. Only 3 people were capable of walking for short distances. Diagnostically every resident had a degree of organic dementia and mental health problems and/or physical disability. This home is now a high dependency environment. It was clear from observation on the day of the inspection that resident dependency was high and staff, whose numbers were further depleted by staff absence, were extremely busy and task orientated. Many residents needed two people to assist them. There is also a house rule explained by the manager that 2 staff must effect all moving and handling transfers to ensure safety. This is commendably good practice, but further reduces the availability of staff to assist or supervise other residents while manoeuvres are taking place. The size, layout and geography of the building adds to staff pressures. In addition, concerns were raised by survey respondents and relatives about the lack of staff at times and language barriers. A resident said they were concerned that staff sometimes speak in their own language, although in the interests of balance, they were also aware that senior staff try to discourage this. Another survey respondent said, ...communication is difficult, I feel that my requests are not acted upon. Relatives meeting notes dated 2/8/2008 make the comment that they wish to see an increase in the numbers of staff attending their high dependency relations. Staffing levels must be based on the homes statement of purpose: admission criteria and specific needs of service users. They must also take into account the numbers of service users, their level of dependency, social, recreational and cultural activities, the training and development requirements of staff, design and layout of the facility and the levels of specific assistance required by people living in the home, i.e. manual handling, behaviors monitoring and supervision requirements. Staffing levels do not demonstrate that residents needs are being met at all times and must be reviewed. If necessary, adjustments must be made to reflect service users changing needs in this home. To that effect, a requirement will be issued in this report. The service recognises the importance of training and delivers a programme that meets statutory requirements and the National Minimum Standards. A requirement will be made however in relation to the communication development needs of some staff. The service has robust recruitment procedures that are regularly reviewed to ensure good practice is being consistently developed. Three Staff files were inspected. It was found that recruitment procedure is followed in practice and there is accurate Care Homes for Older People Page 26 of 35 Evidence: recording at all stages of the process to secure the safety of service users. Care Homes for Older People Page 27 of 35 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered owner and manager are responding to the need for improvements to be made to the service. Some working practices require further development to ensure the safety and welfare of service users is consistently promoted and protected. Evidence: The registered manager completed the fit person process and was registered with the Commission in May 2007. He is a suitably qualified nursing professional, has relevant experience and fully understands his responsibilities. Throughout the inspection he was open and transparently honest. The manager has undertaken periodic training to update his knowledge and skills since the last inspection and is in the process of completing the Registered Managers Award. He explained that there had been some slight delay in completing course work due to situations outside his area of influence, but he is now confident completion will be achieved by the end of 2008. There have been improvements in the home since the last inspection in line with Care Homes for Older People Page 28 of 35 Evidence: statutory requirements and good practice recommendations made. The manager has reviewed some policies and procedures and the home is reporting incidences to the Commission appropriately via Regulation 37 notifications. There have been regular Regulation 26 visits made by a representative of the owner organisation. Regular supervision of staff by the manager and annual appraisal is taking place. The home has achieved the Investors in People Award - This is a national quality standard which sets a level of good practice for improving an organisations performance through its people. There is evidence of the manager being proactive and addressing issues of concern before they become a problem. However, issues regarding staffing levels, strategies for overcoming communication and cultural difficulties between staff recruited from abroad and residents, togeather with some quality of service issues detailed throughout this report, still need to be resolved. Until these items are addressed good outcomes for service users cannot be demonstrated, which will impact on the homes overall quality rating judgment using KLORA. The manager stated that the home sends out surveys to residents, relatives and other associated professionals. The manager informed the inspector that a summary of the findings is generally collated and produced with an action plan. However, no current quality assurance returns were in a format to view on this site visit. The manger said the last response to surveys was a poor one. However, he did explain that 3 issues were raised: 1. The door bell at main entrance was slow to be answered. 2. Residents call bells are sometimes not answered. 3. People do not know who their named nurse is. He stated his firm intention to resolve these matters and said that the provider has also appointed a new Director of Operations to support his role and further enhance the quality of the service being offered at The Elms. The home maintains allowance money on behalf of residents if requested to do so. This is overseen by the owner organisations finance administrator, who keeps written and computerised records. All debits and credits are recorded, all receipts retained. Accounts are audited by a member of the organisations administrative finance staff quarterly. All staff receive mandatory training and records are maintained. Staff are encouraged to undertake NVQs at Level 2 and 3 in Care as standards demand. The manager completed all sections of the AQAA and the information gave a reasonable picture of the current situation within the service. The evidence to support the comments made is satisfactory, although there were areas where more supporting evidence would have been useful. Care Homes for Older People Page 29 of 35 Care Homes for Older People Page 30 of 35 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 4 18 Arrangements and support strategies must exist within the homes recruitment and staff training procedures that are designed to overcome language and cultural barriers between overseas staff, whose first language is not English, and service users to ensure that people living in the home have their choices, needs and preferences understood and complied with. Not all staff evidence they individually and collectively have the verbal skills and cultural understanding to deliver the services and care which the home offers to provide. 05/01/2009 2 9 13 The Registered Person ensures that staff adhere to the homes policy and procedure for the receipt,recording,storage,ha ndling, administration and 29/12/2008 Care Homes for Older People Page 32 of 35 disposal of medicines received into the care home. Residents prescribed topical medicines are not being correctly stored and residents are being put at risk 3 27 18 A review of staffing levels 15/12/2008 must be carried out and kept under review to ensure that staff are provided on all shifts in the numbers and with the experience and skills required to meet the assessed needs of service users and the services own Statement Of Purpose and their published aims and objectives. The registered persons must ensure that there are sufficient staff numbers of suitably qualified, competent and experienced persons working at the home in sufficient numbers as are appropriate for the health and welfare of service users. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 It is recommended that the homes statement of purpose and service user guide are reviewed to ensure they contain all the required information. Good practice demands information documents are clearly dated and evidence a date for review to ensure they remain current. The arrangements for contacting the service by telephone and for receiving visitors in person should be reviewed to ensure they are suitably responsive and meet peoples Page 33 of 35 2 4 Care Homes for Older People needs. 3 7 It is recommended that daily records be maintained in such a way as to consistently reflect that staff are following the guidelines in a residents care plan. This is to provide evidence of the care provided and give sufficient detail on which to base the monthly review and to record and to evidence staff are following the residents assessment of need. It is recommended that the manager consult the NHS End of Life Care Programme which is available on the Department of Healths website for guidance. This guidance provides examples of innovative practice for care homes to follow. It is recommended that the homes complaints procedure is reviewed to ensure content meets fully with the demands of regulation. It is strongly recommended that the manager seek professional guidance from the Health Protection Agency in relation to the homes current practice of using transfer hoist slings communally for residents. 4 11 5 16 6 26 Care Homes for Older People Page 34 of 35 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). 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