Inspection on 08/09/08 for The Elms [Stonehouse]

This inspection was carried out on 8th September 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Elms [Stonehouse] 08/10/07

The Elms [Stonehouse] 16/10/06

The Elms [Stonehouse] 27/02/06

The Elms [Stonehouse] 30/08/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE The Elms Elm Road Stonehouse Glos GL10 2NP Lead Inspector Mrs Ruth Wilcox Key Unannounced Inspection 8th September 2008 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms Address Elm Road Stonehouse Glos GL10 2NP 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) 01453 824477 01453 791813 manager.theelms@osjctglos.co.uk The Orders of St John Care Trust Manager post vacant Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 45 8th October 2007 Date of last inspection Brief Description of the Service: The Elms is a purpose built care home, which provides personal and nursing care for 45 older people. It is situated in close proximity to the amenities of the local town, and is managed by The Orders of St John Care Trust. The accommodation is provided in single rooms, and is situated on two floors, which are accessible using a shaft lift or stairs. Two rooms have an en-suite facility, though all other rooms have a washbasin in situ, with a toilet in close proximity. Communal bathrooms are spacious and provide assisted bathing facilities. Communal space comprises four lounges and a large dining area. There is a small garden and enclosed courtyard at the home, which residents can use if they wish. Information about the home is available in the Service User Guide, which is issued to prospective residents, and a copy of the most recent CSCI report is attached to the home’s Statement of Purpose, which is available in the home for anyone to read. The charges for The Elms range from £553 to £733, and care can also be provided at local authority rates as well. Hairdressing, Chiropody, Newspapers and Toiletries are charged at individual extra costs. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience Adequate quality outcomes. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One Regulatory Inspector and one of our CSCI (The Commission for Social Care Inspection) Pharmacist Inspectors carried out this inspection on one full day in September 2008. In addition to this the services of an Expert by Experience were used to interview residents, in order that residents’ experience could be fully understood in relation to this home. Care records were inspected, with the care of five residents being closely looked at in particular. The pharmacist inspector looked at some stocks and storage arrangements for medicines, some medication records (including the computerised recording system) and procedures. We saw one of the nurses administer some medicines, and we talked with the manager and three nurses. A number of residents and relatives were spoken to directly in order to gauge their views and experiences of the services and care provided at The Elms. Some of the staff were interviewed. Survey forms were also issued to a number of residents, staff and visiting health care professionals to complete and return to CSCI if they wished. Some of their comments feature in this report. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, provision, training and supervision of staff were inspected, as was the overall management of the home. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. We required an Annual Quality Assurance Assessment (AQAA) from the home, which was provided, the contents of which informed part of this inspection. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 6 What the service does well: The Elms provides a welcoming atmosphere for visitors, and ensures that there is a good amount of information about the home, its services and facilities to assist residents and their families. Residents are admitted here on the basis of a full and comprehensive assessment of their individual needs, and upon admission each has their own personal documented plan of care to address their individual needs. Care plans were well written in the main, with only isolated anomalies needing closer attention. Appropriate support equipment was in use on the basis of individual risk assessments, there was evidence of appropriate sourcing of medical reviews and support, and there were many examples seen of residents receiving good care. Medicines were stored safely and managed by trained staff. Residents and their visitors generally speak positively regarding the services and care they receive at The Elms, with one saying that ‘getting good medical support for them was always a priority to the staff’. Most residents are able to choose how and where they spend their time, and there is an expanding social activities programme available. However, it is important that staff continue to ensure that any activity programme remains accessible to all residents, despite any level of disability they might have. The quality and quantity of food served to residents was good, and in the main the residents said they enjoyed their food; just one said ‘it could be a bit hit and miss at times’. People can be assured that the home takes any complaint seriously, and there are policies and procedures in place for the protection of the vulnerable residents. Staff are recruited in accordance with good recruitment procedures, with the necessary pre-employment checks taking place. They are encouraged to develop professionally, and have access to good training opportunities. Staff engaged with residents in a caring and attentive way, although they appeared to be very busy with heavy demands on their time. The home’s AQAA was very well completed, and provided us with the information we required. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Stock control and reordering arrangements for some medicines needed revision. Some aspects of the way medicines were administered and care plans for medicines that were used ‘when required’ need reviewing. Staff must use the recommended lancing devices for obtaining blood glucose samples. Although residents are largely satisfied with the food they are offered, there are some areas where the home should make some slight improvements. These relate to the way in which residents are offered the available options for the suppertime meal, so as to ensure adequate choice in all cases; that catering staff be better informed regarding the specific needs of diet controlled diabetic residents; and that a calm atmosphere be retained in the dining room so that residents can enjoy their meal in quieter and more conducive surroundings. Many parts of the environment appear fatigued, and are showing very evident signs of heavy wear and tear. As such the home is due for some redecoration and floor covering renewal in the near future. We received some good comments about the staff here, but comments also indicated that staff were very busy, and that residents could be kept waiting for attention at times. A very small minority of staff were not as receptive as others towards to the inspection process. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 9 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 DS0000064620.V368555.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A very thorough and comprehensive assessment process prior to admission to the home gives prospective residents an assurance that their needs can be met. EVIDENCE: The home’s AQAA stated that all prospective residents were issued with a copy of the home’s Service User Guide (information brochure), and that all interested parties were given the chance to view and tour the home to meet other residents and staff. A copy of the home’s Service User Guide and Statement of Purpose was on display in the entrance hall. The manager confirmed that the brochure could also be produced in an alternative format if this was needed, such as in Braille or large print. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 11 We inspected two examples of pre-admission assessments, each of which was for residents more recently admitted to the home. Each assessment had been carried out prior to admission being agreed, and had been comprehensively and fully recorded on the home’s designated tool for the purpose. The assessments had been signed and dated, with the location where it was conducted identified. They also identified if the person’s family or representative was present. The assessments took account of their personal details and their past medical history; their health and care needs; their medications; their ethnicity, socialisation and cultural needs; their understanding and legal status. There was also a manual handling assessment; a pressure sore vulnerability and overall skin assessment; a nutritional and a falls risk assessment. Assessment and care plan information had also been obtained from other social and healthcare professionals involved in the care of the individual. Confirmation letters regarding residents’ admission to the home were issued. One person commented on a survey form that the manager and a nurse from the home had visited them before a decision was taken for them to move in. Another said that they had been ‘delighted with their choice’. The Elms does not provide intermediate care. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are mostly safe arrangements in place for meeting residents’ health and care needs, but the inspection highlighted a few weaknesses with the management of medications, where these arrangements need some revision so as to always help protect people living in the home from unnecessary risks with medication. EVIDENCE: New and improved assessment and care planning documentation had been implemented since the last inspection, much of this in very recent months. Certain small gaps remained within it, such as Life History and Pain Assessment Tools not being consistently utilised. We also found some of the plans were derived from a standard template, and it will remain important for staff to make the necessary amendments in order to make the plan more personalised to the resident in isolated cases. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 13 Each resident had their own documented care plan that had been drafted on the basis of an assessment of all their health and personal needs in consultation with them. Recorded risk assessments in each case included pressure sore vulnerability, falls, nutrition and moving and handling. Where other risks existed, such as with the use of bed rails for example, these too had been taken fully into account. Each had been regularly reviewed. We identified very isolated anomalies between care plans that addressed similar areas derived from an individual’s assessment tool, but in the main plans were well written, and provided good guidance for staff when delivering the care. In one case we found that a falls risk assessment review had not taken account of the fact the resident had fallen in that particular month. We found that each person had been medically reviewed on a regular basis, and saw that a wide and comprehensive range of health care interventions had been provided where necessary, and that some very good multidisciplinary approaches had been adopted for the benefit of the residents. Support equipment, such as variable height beds, pressure relieving aids and walking and lifting aids, was in place for those residents for whom it had been assessed as needed. Where closer monitoring was necessary in areas such as pressure relief and diet and fluid intake, specific monitoring charts had been set up for recording in the relevant rooms, which were being maintained by the staff. One person commented that good medical support for them ‘was always a priority to the staff’. The pharmacist inspector reported on the management of medication – Registered nurses were responsible for the management and administration of medicines for people living in this home. The company has provided additional medication training for these staff. The home was using a new computerised medicine management system provided by their Pharmacy as part of a trial that started towards the end of 2007. All records about the medicines received and administered were now available on the computer system. We found that it was possible to review past medication records and view copies of the doctors’ original prescriptions from the computer in the home linked to the pharmacy. As part of this system the pharmacy also each month printed a record for each person of all the medicines the doctor has prescribed with a chart on which staff can record by hand when they have administered medication. This was a backup recording method should the computer system fail or an agency nurse was on duty who The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 14 was not trained to use the computerised records. We saw that the allergy sections of the medicine records were completed and there were photos with each record to help the staff to check they were giving the medicines to the right person. There were also records of the medicines that had been ordered from the surgery and pharmacy. There were suitable arrangements in place for the disposal and recording of any unwanted medicines. Complete and accurate records about medication are important so that there is a full account of the medicines the home is responsible for on behalf of the people living here and so that people are not at risk from mistakes, such as receiving their medicines incorrectly. Records about medication administered were mainly on the computer system but could be on the printed recording charts, so a gap on the computer records does not mean necessarily that the medicine has not been administered. We found this can mean the reports the computer system provides to help monitor and check medication may give misleading information. The manager told us she found some difficulty in auditing medication arrangements using such reports. All the medicines were packed in the manufacturers’ original packs and traditional containers, as with this system each pack has a bar code that is scanned before medicines are administered. This system checks the scanned item with the computer records to check that the right medicine has been selected to give to the right person at the right time. We saw that around 80 of doses administered were scanned (rather than manually). It is good to have a high rate of doses that are scanned, as this should reduce the risk of mistakes with medicines. There were safe storage arrangements for medicines and we saw from the records kept that this was at the correct temperature. There was a proper cupboard in which to store controlled medication but the inner section needs fixing securely (with two rag or rawl bolts on to a solid wall through the two holes in the reinforced plate at the back of this section) so as to comply with The Misuse of Drugs (Safe Custody) Regulations 1973. Checks we made with the controlled medicine stocks and the record book were in order. These medicines were signed as checked each day in the record book. We went into one bedroom and saw that some opened containers of creams or ointments were by the washbasin. These arrangements must be checked as being safe for everyone living in the home and that there is no risk of anyone accidentally using these wrongly. One pot of cream had been opened since 23/07/08; the home’s policy is to replace such containers every four weeks in accordance with good practice guidance in order to reduce risks of cross infection and contamination. Other medicine containers we looked at had opening dates and were being used within the periods stated within the home’s medication policy. Many of the medicine records we looked at indicated that there was proper administration and recording of medicines for people in the home and that the The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 15 medicines were available in the home to administer. We looked in more detail at records for nine people and, as a result, raised the following issues with the manager for action in order help make sure of the safety and wellbeing of people living in the home and of compliance with the Care Home Regulations 2001. We watched one of the nurses administering medicines to some people during the inspection. We were concerned that occasionally the tablets or capsules were placed into a cup after checking on the computer for the doses needed, but were then carried to the person’s room that was distant from the trolley that had the records and labelled containers. Practice like this can put people at increased risk of receiving the wrong medication. We also noted that some people were receiving their medicines rather early in the morning. We were told that the night staff administer morning medicines to some people, mainly on the first floor. Records showed for these people some medicines were due at 6am but records showed some people had their medicines as early as 5.36am. The manager said staff would not wake up residents to give their medicines and we hope this is so. Care plans for each person need to reflect what choices they are given and have made about how their medicines are administered and their consent to the way in which staff manage the medicines on their behalf. This could include information about the times. It is also poor practice for night staff to administer a lot of medication, which is a complex process needing a lot of concentration, at the end of their night shift when they will be tired and more liable to make mistakes. We were told that the home will be having a second medicine trolley which should help with these issues and make it possible for the day staff to administer all the morning medicines within an acceptable time-frame. We saw that records were made of creams or ointments that staff had applied to people and that there were plans in individual care files describing the use of these treatments. This issue was raised at the last inspection. One plan we looked at did not contain the full name of the cream so could imply a different product was being used. We noted that for some treatments the nurses were recording that these had been applied although they had delegated this to other care staff and not seen this done themselves. We discussed with the manager about considering other records that the care staff who actually applied the treatment would complete. We found three examples where improvements in stock control were necessary, as medicines had not been available in the home when needed. Failures such as this are a breach of regulation 13(2) of the Care Homes Regulations 2001. For two people who were prescribed medicated patches for pain relief (applied every three or seven days), new stocks had not been available on the right day to change the patch during the last month so that The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 16 the patches were changed two and three days late. This would alter the effectiveness of the pain relief given by this medication. We also noted that the some of the dates of records on the computer system and in the controlled medicine record book were different leaving some ambiguity as to when the doses were actually administered. Another person was prescribed a particular tablet every seven days. Records showed no doses given for the previous seventeen days. The nurse told us there were difficulties in obtaining the repeat prescription for these tablets, which were now on order. We sometimes found that the medicine stock balances indicated by the computer did not agree with the quantities in stock. This can make it difficult for staff to use the records to make sure that enough medicines are available to administer in the way the doctors have prescribed. For example, we were concerned that sometimes when this happened the computer system did not appear to reduce the stock level by the same number of tablets that the records indicate were administered. Records for one person showed that a dose of analgesic tablets of two twice a day were prescribed and yet on two days recently doses of two tablets three times a day were recorded. The computer records showed the last dose change was on 07/08/08 but that the dose of two tablets twice daily started on 21/08/08. It is hard to understand how the computer permitted this higher dose to be given. There was some ambiguity in the computer records about a recent increased dose of capsules for one person. One of the nurses contacted the pharmacy about this. The computer showed that no doses were given on 6th and 7th September 2008 yet one pack of capsules had an opening date of 06/09/08 and two capsules were missing indicating they may have been given. We looked at some care plans where some medicines were prescribed to use ‘as required’. We found these were often in place but there were examples where the plans needed updating to include all medicines prescribed in this way or to include more information, particularly when there was a choice of dose or use of two medicines with a similar action. For one person a sedative type tablet had a direction to administer one twice a day when required – ‘use sparingly’ yet recent records showed this was given twice a day regularly. We spoke to staff about this who said that this dose was needed. The care plan contained little detail to give staff proper guidance about using this effectively, just stating to give prescribed medication and monitor effects. This particular group of medicines is only licensed for shortterm use. The care plan showed the GP saw this person on 12/05/08 and prescribed this but no evidence was seen of a review since. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 17 The care plan for another person lacked direction about the dose and time interval for the use of an emergency medicine for epilepsy. Blood glucose results for another person were not recorded as being measured daily as the care plan directs. On one day levels were recorded as being low (3.3mmol/l) at 7.15am; the advice noted as a consequence was to have a cup of tea and check again. We did not see a record of another check or evidence of any carbohydrate being given (a cup of tea alone unless there was added sugar would not help with this.) The care plan indicates to give tea and biscuits if the level falls below 3mmol/litre. We noted that this person has swallowing difficulties and has a pureed diet so question if this was a suitable action. All care plans with a blood glucose range need checking, as the British National Formulary states a range between 4 and 9 mmol/l and to make strenuous efforts to prevent falling below 4mmol/l. The plans we saw stated the range as 3 to 9 mmol/l. We also found that the lancing device the nurses were using to obtain capillary blood samples (to measure blood glucose levels) on a number of people living in the home was not in accordance with Medical Device Alert MDA/2006/066 dated 6th December 2006. This can put people living in the home at a known risk of transmission of blood borne infection. Staff are also at risk from needlestick injury and cross contamination. The correct lancets are available on NHS prescription. Some tablets for another person were being crushed, and together with other dispersible tablets or liquid medicines, were administered via a feeding tube. There was a care plan but this needed more information and to consider the issues around crushing tablets (the pharmacist would be able to help with this). As this is an unlicensed way of administering medicines the prescription from the doctor must contain the directions to administer by the feed tube. We visited this person in his/her bedroom and it seems unlikely that he/she had the capacity to consent to medication and administered in this way. Records should be made therefore of the agreement of those significant people involved with the care of this person that the way in which medicines are administered is in their best interests, in accordance with the provisions of the Mental Capacity Act 2005. There was a medication policy and procedures available so that all staff were aware of how the company expected medication to be handled in a safe way. This has been revised in May 2008 but does not contain reference to the new computerised medicine management system. The company should consider providing additional policy information in those of their homes using this system. There were protocols for using homely remedies and there were separate stocks of these with a separate record book. We pointed out correction of records was needed for one medicine used for indigestion. The product we The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 18 saw administered was different to what was included on the computerised record and in the stock control record book. Visiting healthcare professionals confirmed on survey forms that they were very satisfied with the standard of care their patients received here, saying that residents’ health needs were met in a way that respected people’s privacy and dignity, and that they were called appropriately to the home by professional and caring staff. We observed staff, although very busy and with a high level of demand on their time, as very attentive towards the residents, tending to them with due respect to their individual needs and condition. Care was delivered in the privacy of residents’ rooms, and staff carried out duties in a discreet manner. In cases where poorly residents were being nursed in bed, doors had been left ajar, and staff needed to remain vigilant in such cases so to ensure that the occupant’s privacy and dignity was constantly protected. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 19 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. With staff vigilance, people living in this home have the opportunity to remain socially active, exercise choice, and have a nutritious diet that offers choice and variety. EVIDENCE: The home has a designated social activities coordinator; the AQAA stated that the number of hours this person works had been increased. The coordinator told us that she was aware that many of the residents needed one-to-one type activity, as well as the organised group activities. One resident told us that they had difficulty accessing the social activities due to their poor hearing and vision, so it will be essential for the coordinator to remain mindful of this to ensure that all can access opportunities for social engagement regardless of disability. We saw a group activity taking place during the afternoon, and those requiring more help to participate were being appropriately supported. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 20 The activity programme was displayed, and the coordinator was seen discussing it with residents in their rooms during the morning. The programme included a variety of activities to suit differing tastes, and included visiting entertainers, occasional outings, larger social events and observation of special calendar dates. A book library was available, and some residents had their own televisions in their rooms. We could see that television reception was poor for some people, and ways to overcome this were being explored by the home. There was a monthly religious service held in the home, and a small number of residents were enabled to attend church on a Sunday. The AQAA stated that the home was considering ways in which it could improve its links within the local community. Visitors were free to come into the home whenever they or their relative liked, with the home imposing no restrictions upon them. We spoke to two visitors, and each of these was very complimentary regarding the care that their relative received in the home. Many residents were very dependent on staff, with a large number being immobile or bed or chair bound, and as such relied on staff to remain vigilant and attentive towards their opportunity to express choice. Those who were less dependent were able to move around the home in accordance with their wishes, and were free to choose how they spent their time. We witnessed staff offering choices to residents in kind and sensitive ways throughout this visit. Visiting healthcare professionals confirmed to us that the home gave residents the necessary support to live life as they chose. There was a variety of information available for people should they have wanted or needed it, regarding support, advice and advocacy services. Residents were able to choose what they had in their own rooms, with some having a more personalised and individual appearance as a consequence. We saw the service of the lunchtime meal. The meal appeared hot and appetising, and was served in the light and airy surroundings of the dining room. At one point the dining room became slightly disruptive for residents, with the large medication trolley being wheeled through, wheelchairs being brought in after the meal had started, and with the television on. We saw that two residents who felt unwell were served soup in their rooms. Staff were on hand to help those who needed feeding and to top up drinks where needed. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 21 The menus showed a good choice of food, with at least three other options provided according to preference, quite separately from the two main choices on the menu. The supper list showed a much reduced choice, with only soup or sandwiches available. We were told that there were other hot options for supper, but that the choice list from which residents made their personal selection was not entirely reflective of what was actually available; this was an area that the manager recognised they needed to improve upon if residents were to be assured of sufficient choice in the evening. Residents spoke favourably about the quality and quantity of the food provided for them, with one saying that ‘There is a very good choice of food with good helpings’. Conversely one resident said that ‘it could be a bit hit and miss sometimes’. Residents’ special diets were catered for, but the cook was not entirely conversant with the needs of a diabetic resident. The kitchen was clean and orderly, although a large food delivery had come in and one of the deep-freezers had broken down; this was replaced by the afternoon. Good catering records were in place. Training records showed that kitchen staff had undergone appropriate catering training. The AQAA stated that the home had achieved a five star rating award from the local council for its standard of catering. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 22 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this home are generally reassured by the home’s complaints procedures and the policies regarding the prevention of abuse. EVIDENCE: The home had a clearly written and accessible procedure for addressing any concerns and complaints; a copy was issued to all residents and their families. Each person who responded on our survey form confirmed that they knew how to raise concerns with the home if they had any. The AQAA stated that the home had dealt with five complaints in the past year. We viewed the records in relation to these concerns, the majority of which had been verbal concerns, and each contained evidence of actions taken and resolutions reached in each case, including investigation notes and correspondence. Prior to this inspection a visiting Social Care professional had shared information with us regarding some specific care concerns for one particular person. This person had stayed in the home for respite care, and had remained dissatisfied about certain aspects of her stay. We discussed these issues with the manager who recounted the circumstances to us. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 23 The home had documented policies and procedures to address forms of abuse and whistle blowing, which were readily available for staff to read. Staff had access to the Mental Capacity Act 2005 ‘easy-read’ version, and had received some in-house instruction in this area through the supervision programme. The manager told us that the home had recently introduced an ‘Advanced Directives’ policy, and that this would now require some particular attention and focus in order to implement it fully for the residents. Staff had received training in safeguarding vulnerable adults, and during interview those spoken to confirmed their awareness and understanding; some were more able than others to demonstrate their knowledge of the designated adult protection unit within the local authority, and any potential role that the police might have. One of the resident’s relatives told us that her ‘Mother felt very safe here’. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in this home are generally provided with accommodation that is suitable and safe to meet their needs, however aspects of it are in need of repair, and this is currently impacting on the otherwise pleasant surroundings for residents. EVIDENCE: The home had a designated maintenance person, and also had maintenance and servicing contracts with external contractors to ensure that the home is safely maintained for the residents. We saw well-kept maintenance records. Since the last inspection at least ten new beds and some new dining room curtains had been provided. A new greenhouse had been erected for the residents. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 25 However despite this, the home was showing clear signs of wear and tear in a number of locations, with damaged woodwork and walls in need of attention, and some carpets looking dirty, stained and heavily worn. The manager acknowledged that this was the case, and had a clear direction to improve this in the short term. The front entrance hall was fully used by residents, with the area becoming a social hive of activity on occasions. There were a number of other comfortable sitting areas where residents could sit or receive their visitors. The home now offered a smoke-free environment. Residents’ rooms varied in size, and some of them appeared quite cluttered, not necessarily due to untidiness, but the storage of commodes, walking frames, wheelchairs and other supplies in some cases. One person commented on the home appearing ‘a bit shabby in places’. The laundry was well equipped, with machines capable of sluicing and disinfecting foul items. The laundry assistant was experienced, and was conversant in the necessary infection control procedures. The sluice rooms were reasonably tidy and clean, and all grades of clinical waste were correctly managed. There were copious amounts of gloves, aprons, liquid hand washes, paper towels and sanitizers around all areas of the home. The numbers of cleaning staff had been increased, with the home generally clean. However, there was some stale odour detected in the hall and ground floor corridors, where the carpets, as reported above, were dirty. We were assured that this area was due for redecoration, and that when this had taken place the offending carpets were being replaced; this was reported to be imminent, with the carpets already ordered. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this home receive care from a competent work force, who undergo full pre-employment checks, and who are supported to train and develop professionally. EVIDENCE: Staff rotas showed that there was routinely at least one registered nurse on duty over a twenty-four hour period, with two during the mornings. There were nine carers allocated to the mornings, with at least six for the afternoon and evenings, and three overnight. The manager worked in a supernumerary capacity, and there was an ancillary team of catering, cleaning, laundry, maintenance and administrators supporting the nursing and care team. The number of domestic staff had increased, with an improved amount of cleaning time. The deputy manager also had some supernumerary time. Recruitment of staff was ongoing, with an increasing number of more permanent members; however some agency staff were still being utilised at this time. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 27 The dependency levels in the home were high, and staff were constantly busy, with some significant demands on their time. Call bells were heard ringing regularly, but appeared to be answered reasonably promptly. We saw that the staff team engaged with the residents in a positive and caring manner. Residents spoken to or responding to surveys reflected favourably on staff, with comments received such as ‘They are all friendly and helpful, but they can only do one job at a time’. Others included, ‘The majority of them are tolerant and dedicated’ and ‘They work well together’. Less positive comments included, ‘The heavy demands on them can affect their responses’, ‘It’s difficult getting help, particularly after lunch due to staff breaks and handovers’, and ‘They are just too busy at times’. Some of the visiting healthcare professionals viewed the staff as having a good understanding of people’s needs, and commented that the home had ‘some professional and caring staff’. Staff themselves confirmed, one rather more forcibly than the others, that the home was very busy. Some were more open, welcoming and cooperative towards the inspection process than others. The home was making excellent progress with the National Vocational Qualification (NVQ) training programme for care staff. Twenty carers were qualified to at least level 2, with a further two staff currently on a course. We inspected two staff files of recently recruited carers. In each instance, the prospective employee had completed an application form providing details of their employment history, with evidence that any gaps in it had been explained; interview notes confirmed that these had been explored and discussed as well. Two written references had been provided in each case, with at least one of each of these having been obtained from the previous employer. Proof of identity and medical statements had been obtained. Correct POVA (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) screening had been completed for each person well ahead of their commencement of employment. Each file contained an employment contract, a job description, and evidence of equal opportunities and sickness monitoring. The manager had been auditing the computerised training records, identifying any skill and learning gaps within the team. The training coordinator also maintained paper records. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 28 Training records showed that staff had received training in dementia care, safeguarding vulnerable adults, infection control, and health and safety. The home had a range of DVD learning material that was being used to provide updated instruction in a number of areas relevant to the work. One of the care staff was a trained moving and handling trainer, and provided refresher training in this area. We saw records of in-house induction training for new staff. We were told that the way in which induction training was delivered was due to change, with formal induction to the Trust being delivered actually within the home as well. New workers also underwent computer-based training in the Common Induction Standards for care workers, with the aim being for them to commence this part of their induction within six weeks of their employment. One new worker was working under the supervision of an experienced care leader. Another worker said that they had done the same, and had experienced some good support whilst being inducted to the home. Staff confirmed that they had some good training opportunities, and that mandatory training in particular was very good. One person commented on survey that they would like to have workshop style training in Equality and Diversity. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 29 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements to the management systems in place here have ensured that the interests, health and safety of the residents living in the home can be safeguarded. EVIDENCE: The new manager of the home is an experienced manager, having been the registered manager at another home within The Orders of St John Care Trust group. She is a first level nurse and has achieved the Registered Manager Award. An application to register her with CSCI is currently under consideration. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 30 The manager’s aim since coming to The Elms has been to establish a more cohesive staff team that will focus on its primary objective of delivering good care to the residents. Staff said that they were finding their new manager approachable, and there was evident appreciation of her habit of working alongside staff and remaining very accessible. Some said that ‘some of the newly introduced working practices would take some getting used to’. The manager demonstrated a very clear directive towards stabilising and improving the home in all areas, and had been carrying out a range of internal quality audits as part of this commitment. The Assistant Operations Director had also been carrying out a number of internal quality audits as well. External assessors had also successfully assessed standards at The Elms for the ISO quality award. The home’s AQAA was very comprehensively completed. An annual survey had recently been issued to residents and their representatives in order to gain their views and experiences of the home as part of a quality monitoring approach. This survey had also included the views of some visiting health care professionals as well. Residents and their families had also had a six monthly review of their care, with their views and ideas about the home obtained as part of the ongoing quality monitoring approach here. We were told that residents and their families were viewing this exercise very positively. There were also regular opportunities for residents and their relatives to attend meetings to discuss any issues and ideas about their home. A number of residents had chosen to place personal money with the home for safekeeping. The systems for managing and safeguarding these arrangements were satisfactory and totally transparent. Due to changes not under the home’s control, staff now had to look into the way in which residents’ pension money transfers were handled, with individual bank accounts becoming the changed option. A staff supervision programme was in progress, and some examples of associated records were seen; these included a paper matrix to plan and monitor the programme. Supervision had encompassed areas of practice, issues related to the home, and ideas and development opportunities. Annual appraisals had also taken place as part of this programme. Staff confirmed to us that they had regular access to the manager to discuss their work. The home had written policies and procedures in relation to the promotion of the health and safety of the residents, visitors and staff, and associated training was provided for staff. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 31 Records showed us that regular safety checks and planned maintenance visits had been carried out on the fire safety systems. Evacuation aid equipment was in place, and residents had a fire safety risk assessment in their care plan. Fire safety training had been delivered to all staff, and this had incorporated evacuation procedures in the event of a fire. There were records of two fire drills carried out in May and August of this year. Hot water temperatures were regularly checked for safe levels, and regular Legionella checks on the water supply had also been carried out, with the appropriate control measures in place. The necessary safety checks and maintenance of utilities and equipment had been undertaken in a timely fashion, and the associated records were kept in these areas. One of the home’s resident lifting hoists was out of action and awaiting repair. This was posing some challenges for staff in terms of the availability of the remaining number in different areas of the home. We were assured that this hoist had been prioritised for repair. First aid facilities were widely available. Training to date had been cascaded to care staff from the specialist care leader, however further training in this area was due to be provided by an external specialist training provider to all staff. Accident records were checked and were up to date with notifications that had been sent to CSCI. The manager was reviewing COSHH (Control of Substances Hazardous to Health) risk assessments at the time of this inspection, and all chemicals in use were safely stored. The home was secure, with coded door entries in appropriate places. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 32 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 4 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Revise arrangements for the stock control and reordering of medicines to make sure that all medicines needed are always in stock and available for administration to people in the home in accordance with the doctors’ directions. This is to make sure that people living in the home receive the correct amount of their medicines in the way the doctor prescribed. Carry out a risk assessment of the actual medicine administration process and times and review and introduce safer practices as a result. (This particularly relates to the very early times some morning medicines are administered, night staff administering a significant number of medicines and the practice of sometimes carrying just pots of medicines around the home). This is so that when medication is administered to people living in the home the risk of mistakes is reduced to be as low as possible and will help to make sure each DS0000064620.V368555.R01.S.doc Timescale for action 31/10/08 2. OP9 13(2) 30/11/08 The Elms Version 5.2 Page 34 3. OP9 13(2) 4. OP9 13(3) person receives his or her correct medicines at a suitable time. Fix the inner controlled medicines cupboard in a way that complies with the Misuse of Drugs (Safe Custody) Regulations 1973. This is to make sure these medicines are stored securely and in accordance with the law. When staff take blood samples for blood glucose monitoring make sure that all lancing devices used comply with the action contained in MDA/2006/066 and are safe to use in care homes. This is to protect people living in the home and staff from known risks of cross-infection linked with the use of the wrong sort of lancing device 31/12/08 31/10/08 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 OP7 Good Practice Recommendations The manager should ensure that staff include reference to recent falls residents may have had in their written reviews of falls risk assessments, amending care plans where needed. Where creams and ointments are stored in bedrooms make sure the arrangements are safe for everyone in the home. Review and update the individual care plans written for medication prescribed for use ‘when required’ so that there is always clear written direction to staff on how to make decisions about administration for each person and medicine. This will help to make sure there is some DS0000064620.V368555.R01.S.doc Version 5.2 Page 35 2. 3. OP9 OP9 The Elms 4. OP9 5. OP9 6. 7. 8. OP12 OP15 OP27 consistency for people to receive the correct levels of medication in accordance with their needs and planned actions. Care plans should reflect what choices people who live in the home are given about how their medicines are administered and their consent to the way in which nurses administer their medicines. Where consent is not possible because of lacking capacity records should be made of the agreement that the way in which medicines are administered is in the best interests of that particular person in accordance with the provisions of the Mental Capacity Act 2005. (This particularly relates to the administration of some medicines via a feeding tube and the early morning times some medicines were administered.) Review the recording arrangements for medicines applied externally and consider alternative formats that allow the member of staff who has actually applied the treatment to accurately record this. The staff should take steps to consistently ensure that opportunities for social activity are made accessible to all residents, regardless of any levels of disability. The manager should ensure that all catering staff have full understanding about the needs of all diabetic residents. The manager should review the staff deployment to ensure their availability to residents at peak times. The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Elms DS0000064620.V368555.R01.S.doc Version 5.2 Page 37 - 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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