Inspection on 01/12/06 for The Royal Elms

This inspection was carried out on 1st December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Royal Elms 23/10/07

The Royal Elms 18/07/07

The Royal Elms 10/04/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Royal Elms The Royal Elms 23 Windsor Road Newton Heath Manchester M40 1QQ Lead Inspector Sarah Oldham Unannounced Inspection 1st December 2006 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Royal Elms DS0000067697.V322517.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 Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Royal Elms Address The Royal Elms 23 Windsor Road Newton Heath Manchester M40 1QQ 0161 681 9173 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) Rajanikanth Selvanandan Michelle Lawton Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home will only provide a service to a maximum of 26 people whose primary need for care arises from old age. The matters detailed in the attached schedule of requirements must be completed within the stated timescales. 18 July 2006. Date of last inspection Brief Description of the Service: The Royal Elms Care Home is a care home offering personal care for 26 elderly persons. The home does not offer nursing care. The home was recently purchased by Mr Rajanikanth Selvanandan and commenced a new registration in September 2006. The accommodation is provided on two floors in a Victorian style building, which is serviced by a passenger lift to all levels. The home has a modern extension that provides accommodation for five of the 26 residents accommodated at the home. The entrance to the home is at ground level and the garden area is accessible to all residents. The home benefited from the provision of a large garden to the rear of the property. It is set among similar sized well-established residential properties. There are three lounges, one of the lounges is the smoking area, As previously mentioned the home provides personal care for 26 people there are two double rooms and twenty two single rooms, six of the single rooms provide en-suite facilities. There is an enclosed parking area to the front of the property offering off road parking for approximately eight vehicles. The home is situated in the Newton Heath area of Manchester close to good public transport links to Manchester City Centre and Oldham. Fees for the home are £373.54 per week with additional charges for hairdressing, chiropody and continence aids. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection site visit was made to the home on the 1 December 2006 as part of the inspection process. The inspection was carried out by one inspector and the inspection visit lasted four hours. The home was not told about the visit beforehand. To help write the report information provided by the home was taken into account and also information the Commission for Social Care Inspection (CSCI) holds on the homes file. During the visit the inspector spoke with residents, members of staff. Visitors and visiting health professionals. Each section of this report contains a judgement about the quality of the service provided. In making the judgement the inspector has considered all the information available, this includes the site visit and information from residents and staff. At the last inspection the home was asked to do a number of things to improve the home so that it is better for the residents. Some things have been put right but some remain and these are included at the end of this report. What the service does well: Residents’ at the home said that they had a good relationship with the staff. One resident said “they are all kind and helpful”. Another said “I feel very settled here”. Staff were seen to be supporting residents with their care needs appropriately and treated them with dignity and respect. The home welcomed visitors and did not place any restriction on visiting times. Visitors spoken to said that they felt the level of support and care given to their relative was good and that they always felt welcomed into the home. Another visitor said “ Staff always keep me informed of how my relative is”. Several residents commented that the food was “nice and there is always a choice”. Staff and residents said that the new owner of the home was there on a regular basis and spent time talking to residents and staff. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although work on residents care files had been undertaken this needed to continue to ensure that all residents had a clear care plan that reflected their current needs. Reviews of care plans was ongoing but needed to be undertaken on a regular basis. The home had commenced redecoration in some areas of the home. The manager said that this was ongoing although there did not appear to be a renewal and maintenance plan available. The manager was unsure of the plans that the new owner had with regards the redecoration of the rest of the home. Staff records had been audited however shortfalls identified at the previous inspection had not been fully addressed. This included making sure that all training undertaken or planned for individual staff was clearly recorded. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 7 Activities were made available for the residents however some residents felt that a greater range of activities should be available. Resident meetings were not held on a regular basis and there was no evidence to show that residents had been fully consulted about activities or planned events within the home. 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 Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 8 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 Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 9 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): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their family/representatives are able to visit the home to enable them to make an informed choice about living there and to ensure that the home was able to meet the person’s needs. EVIDENCE: Since the last inspection the home has not had any new residents’. The manager was however, able to explain the process that she would undertake prior to a new resident moving into the home. This included wherever possible an assessment being undertaken by herself or the deputy manager to ensure that the home was a suitable placement for the individual and that their needs could be met there. The manager said that a copy of the assessment completed would be maintained on the residents’ file if they moved into the The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 10 home. The manager said that previously there had been difficulties obtaining an assessment that had been undertaken by a care manager but this was now a requirement of the home prior to accepting any new referrals. This assessment would also be included on the resident’s file. Prospective residents were offered trial visits to the home prior to admission taking place to enable them to make an informed choice. The home did not provide intermediate care. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 11 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. Care plans did not fully reflect the needs of the residents. This could result in the residents’ personal care, health and safety being placed at risk. EVIDENCE: At the previous inspection the management were in the process of changing the care plan format. Following the purchase of the home this had continued. At this inspection there was clear evidence that further work had been undertaken with regards residents’ care plans and the identified outcomes for each individual resident. The home had identified a specific care plan format to use, however, not all of the care plans had been transferred onto the new care plan format. The manager said that this work was ongoing and felt that the timescale for the completion of this would be two months. The requirement The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 12 regarding care plans from the previous inspection was made again at this inspection and should be treated as a priority to ensure that there is a consistent and clear care plan format for all the resident’s at the home. Staff spoken to were aware of the needs of each resident and also had been involved in the development of the care plans. Training and support for staff with regards the care planning process was ongoing. The service manager, manager and deputy manager were undertaking this with staff. Residents spoken to were also aware of the care plan for them and had been involved in their own care plan. There was evidence that some existing care plans had been reviewed and the manager confirmed that this was ongoing. Records relating to health care appointments were recorded on a separate file sheet for individual residents. This enabled an overview of the current health care needs of individual residents. At the time to the visit to the home the medication was seen to be stored appropriately and the Medication Administration Record (MAR) sheets had been completed. All staff with the responsibility for handling and managing medication had received training in the Safe Handling of Medicines. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents had limited choice and support to meet their expectations and preferences regarding their daily lifestyle. EVIDENCE: The home had reviewed some of the activities available for the residents. Residents spoken to said that they were able to join in activities if they wished to do so. One resident spoken to said that although activities were available she did not feel that she had to ‘join in’ with them if she didn’t wish to do so. Residents had the opportunity to socialise in the communal areas of the home or in the privacy of their own room. The manager said that in the past resident’s meetings had taken place but that one had not been held for a few months. There were plans to recommence these meetings in the New Year. It was recommended that these meetings The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 14 were recorded and made available to the residents to ensure that their opinions and views were listened to and acted upon. Meals provided at the home offered a choice and appeared to be nutritionally balanced. The home has a four-week plan of menus that are reviewed and updated every three months. Residents’ spoken to said that the meals were very good. One resident said “ I really enjoy the meals here and there is always a good choice”. Another resident said “ I look forward to my meals here they are really nice and I am able to choose things I like”. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to promote the protection of the residents’ at the home. EVIDENCE: The home had a complaints policy and procedure in place. Details of this appears in the Statement of Purpose and Service Users’ Guide. A number of residents spoken to said that if they were unhappy about something they would speak to the manager of the home or their relative. One resident said “ I know that if I have any concerns or complaints then the manager will listen and try to sort it out”. The home had policies and procedures in place regarding the Protection of Vulnerable Adults. Some staff had undertaken Protection of Vulnerable Adults training to ensure that they were able to identify protection issues however, this training had not been recorded on individual staff members training records. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 16 Prior to the previous visit to the home the service manager had undertaken an audit of staff files. It was identified that some members of staff had not had an enhanced Criminal Records Bureau (CRB) disclosure or a Protection of Vulnerable Adults (POVA) first check. The service manager had applied for further enhanced disclosures however, there were still some that had not yet been received. The manager and service manager were made aware of the need for disclosures to be undertaken prior to the commencement of employment to ensure the safety and wellbeing of the residents at the home. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 17 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. The home was generally clean and comfortable although there were some parts of the building that required maintenance and refurbishment. Residents’ bedrooms were personalised and comfortably furnished. EVIDENCE: Following the purchase and new ownership of the home there was evidence that some areas had been redecorated and flooring in en suite bathroom and shower rooms replaced. The manager said that a programme of redecoration and maintenance was ongoing although this was not available at the time of the visit to the home. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 18 The dining area and lounge had been redecorated, however, the carpet in this area had not been replaced. At previous visits to the home as part of the inspection process it had been noted that the bold strip design of the carpeting raised some concerns as it was felt that the carpet design could present as a hazard for those residents with limited vision who could confuse the strips for steps. The service manager said that this had been raised with the new owner of the home. The home had a maintenance person who was responsible for undertaking routine maintenance and the service manager and manager did a general tour of the building each week. It had been noted that one of the windows at the top of the stairs did not have a window restrictor in place and this was being addressed at the time of the inspection. Laundry facilities for the home remained situated in the basement of the home and the manager said that an audit of equipment was being undertaken to ensure that the home was provided with appropriate laundry equipment. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels at the home appeared to be adequate to meet the needs of the residents at the home. The manager said that staffing levels were reviewed according to the needs of the residents. At the previous site visit to the home it was found that staff had been employed prior to receiving satisfactory Criminal Record Bureau enhanced disclosures. The service manager had applied for all outstanding disclosures although at the time of this site visit not all had been received back. The home had not appointed any new staff and the manager and service manager said that they were aware of the procedures to follow with regards recruitment and selection. There was evidence that staff training had been undertaken however some areas of training were outstanding. The service manager is responsible for the training of staff and had developed a planned training programme. The manager said that she was intending to undertake a full audit of all staff files The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 20 to ensure that the records maintained reflected the training that staff had undertaken. Following the full audit of staff files identified at the previous site visit there was still some information missing on individual staff files and they did not adhere to Schedule 2 of the Care Home Regulations 2001. A requirement had been made at the previous inspection and was reiterated. There was evidence that formal supervision for staff had taken place and the manager said that she was in the process of arranging supervision for staff for the following twelve months. Staff spoken to confirmed that they received both formal and informal supervision on a regular basis. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 21 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,& 38. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home had significant areas that required additional management to promote the health, safety and well being of the residents living at the home. EVIDENCE: The manager had returned to work at the home following a period of sick leave and had commenced a review of the recording systems within the home. In addition to this the home had recently been registered under new ownership. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 22 The manager had commenced work with regards the requirements at the previous inspection and although not all of this work had been completed there was evidence that this work was ongoing. Certificates with regards servicing health and safety equipment were seen and found to be in order. The home did not act as appointee for any of the residents. Personal allowances that residents requested that the home kept in the safe for them were clearly recorded and each resident had a separate facility for storage of their monies. Receipts for purchases were maintained on individual financial record sheets. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 28/02/07 2 OP8 12 3 OP12 16 4 OP29 19 The care plan must be developed in conjunction with the resident and signed by the resident and or their representative The care plan must contain 28/02/07 details of all the residents’ health care needs and details of involvement of health care professionals. The home must consult residents 28/02/07 regarding their social activities and make details of activities available accessible to all residents’. All staff working within the home 28/02/07 must have a Criminal Record Bureau (CRB) disclosure undertaken prior to commencement of employment. Where there is an identified risk to the residents due to low staffing levels a member of staff can be appointed with a Protection of Vulnerable Adults (POVA) first check whilst awaiting the return of the CRB providing they are supervised at all times. The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 25 5 OP29 19 Staff files must contain all details 28/02/07 identified in Schedule 2 of the Care Home Regulations 2001. The provider must ensure that there is a staff training and development plan that is kept up to date and reviewed on a regular basis The registered person must ensure that a process of quality assurance/monitoring, based on seeking feedback from residents and other interested parties, is implemented (Timescales of 30/09/05 and 31/03/06 not met). All staff must receive training on a planned basis to ensure that they have the necessary skills to undertake their role 28/02/07 6 OP30 18 7 OP33 24 28/02/07 8 OP38 18 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 OP19 Good Practice Recommendations It is recommended that minutes be kept of meetings held between the cook and residents when planning menus etc It is recommended that a programme of routine maintenance and renewal of the fabric and decoration of the premises is produced and implemented with records kept. It is strongly recommended that the consideration be given to replacing the carpet in the dining room and lounge. 3 OP20 The Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Royal Elms DS0000067697.V322517.R01.S.doc Version 5.2 Page 27 - 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. 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