Care Home: Elmstead

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What the care home does well Elmstead provides a safe, caring and secure environment to their Service Users, treating them with dignity and respect and delivering person centred care. Elmstead is a comfortable, safe, warm and friendly environment; the home is well maintained, decorated and furnished to a good standard. The management and staff have an empathy with the people in their care, this was evidenced by the interaction between the management and staff team with the people who use the service; this was observed when walking around the home talking to the people who use the service and their visitors; the questionnaires received also stated that they “always receive the care and support they need” that the staff are “available when they need them” and that the staff “listen to them and act on what they say”. The following shows what the service does well ,ensuring that the people in their care receive a good standard of care making sure that their assessed personal, health and social care needs met:• The QUEST assessment and Personal Care Planning programme includes specific sections on resident choice. • QUEST is focussed on personalised care and increased opportunities for resident involvement on choice. • The Personal Best programme aims to ensure the views of the people who use the service are always at the forefront of the care provided • The organisation conducts annual Customer Satisfaction Surveys both internally and externally. • Complaints and compliments policies and procedures. • Resident / Relative meetings Bi-annually. • Monthly Reg 26s include discussions with residents and relatives. • Comments and suggestion forms are available in reception and Thank You forms which promote Personal Best. The home manager has an open door policy for the people who use the service, their relatives and the staff of the home, thereby ensuring consistent communication enabling any concerns raised to be resolved quickly and to the satisfaction of those involved.ElmsteadDS0000006930.V376191.R01.S.docVersion 5.2 What has improved since the last inspection? The home manager has highlighted areas for improvement and has worked with the staff team to implement the corporate changes. The environment has improved and all staff are encouraged to participate in some way to maintain this; teamwork has been re-established and the home has a “good-life” feeling • Residents and relatives are involved in Personal Care Planning. • The focus is on the resident’s day. • Regular communications to keep residents and relatives information of the choices and developments in the home. • The views of our services users influence menu choices. • Refurbishment programme due in 2009. • Activities programme has been enhanced and a wider choice available. • Staff levels have increased, a bank staff system has been established and now there is no need for the service to use agency staff. What the care home could do better: The Home Manager is aware of the need to maintain and improve the communication that has been effective with those who have contact from external providers and to maintain community links with those established over the last year. The Home Manager is continuing to improve the following concentrating on providing the best possible care for the people who use the service by focussing on the following areas and making sure that they are implemented:• • • • • • • • Rigorous recruitment policies and procedures. Care is more person centred. Diversity training on request. The Menu Manager programme provides help with developing meals for different dietary needs. Staff are supported where residents make inappropriate remarks Ongoing training. Regular reviews of policies and procedures. Personal Plans being regularly monitored with a specific view to equality and diversity.ElmsteadDS0000006930.V376191.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Elmstead 104 Elmstead Lane Chislehurst Kent BR7 5EL Lead Inspector Sue Meaker Key Unannounced Inspection 23rd June 2009 10:00 DS0000006930.V376191.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmstead Address 104 Elmstead Lane Chislehurst Kent BR7 5EL 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) 020 8467 0007 020 8295 3133 cheesec@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Caroline Susan Cheeseman Care Home 49 Category(ies) of Dementia (14), Old age, not falling within any registration, with number other category (35) of places Elmstead DS0000006930.V376191.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 Only - Code PC 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 - Code OP (maximum number of places: 35) 2. Dementia - Code DE (maximum number of places: 14) The maximum number of service users who can be accommodated is: 49 Key Inspection 9th & 10th May 2007 Random Inspection 2nd October 2007 Annual Service Review 2nd July 2008 Date of last inspection Brief Description of the Service: Elmstead is a care home operated by BUPA, and caters for thirty elderly frail people and fourteen elderly people with Dementia. The care home is located in Chislehurst, Kent within the London Borough of Bromley. The home is a large three storey detached building situated on a busy thoroughfare in a residential area. There is limited off road parking to the front of the building, and a pleasant secluded garden to the rear of the building with a patio and seating areas. The home offers accommodation to a total of forty-four residents in single rooms. Nine of the bedrooms in the home have en suite facilities while the rest have wash hand basins and access to toilet facilities and bathrooms within the home; bedrooms are well decorated and furnished to a high standard; as are the communal areas of the home. Each of the three floors has two bathrooms and a separate shower room, as well as separate toilet facilities; bathrooms and toilets benefit from specialist moving and lifting aids such as hoists and parker baths. Bedrooms, bathrooms and toilets are fitted with locks to ensure privacy; staff in the event of an emergency can access rooms. All communal areas, within the home, are well maintained and provide pleasant seating areas that are easily accessed by the residents and their visitors; a passenger lift gives residents access to the first and second floors of the home. There are individual kitchens on each floor, so all meals are served in the individual units; residents are able to choose to dine with other residents Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 5 or in their own room. Each of the units has a themed communal area. There is a café on the ground floor in which residents and their visitors can sit and enjoy a chat over a cup of tea. The middle floor has a communal lounge that has an organ used for musical interludes for the residents and the top floor has a pub called the Elmstead Arms, residents and their visitors have an open invitation to pop in for a game of cards or join in one of the karaoke sessions. Residents from any of the units are encouraged to access these facilities. The home also has a day centre that caters for older people needing day care. The centre is open six days a week and has separate dining and activities facilities and its own staff team. This area is also used for social events such as Christmas and Easter parties. Residents have access to a telephone and are able to make calls when they wish; there is also provision for residents to have a telephone in their own room at their own expense. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star – good service. This means the people who use this service experience good quality outcomes This was an unannounced key inspection that took place on the 23rd June 2009; the inspection was facilitated by the home manager. Currently the home has 24 people in the residential units and 12 people in the unit that caters for the care of those with dementia; there are 6 vacancies. In addition to the home manager, there was care manager, a senior carer and eight care staff, an activities co-ordinator, a chef and kitchen assistant, a laundry person and domestic staff, an administrator and a maintenance person. Currently the home has a vacancy for a deputy manager, an acting deputy manager has been appointed until a permanent replacement can be found. Before the visit we looked at:Information received since the last visit on 2nd October 2007 which was a random inspection; and from information received since the Annual Service Review on the 2nd July 2008. The Annual Quality Assurance Assessment (AQAA); The AQAA gives the Care Quality Commission evidence to support what the service says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are for improving the service. How the service has dealt with complaints and concerns since the last inspections. Any changes to the organisation and operation of the service. The providers view of how well they care for the people currently living in the home. The views of the people who use the service, their relatives, staff and other professionals who visit the service. During the visit we:Talked with the people who use the service, their relatives and friends, the staff, the registered manager and visitors to the home. Looked at information about the people who use the service and how well their assessed personal, health and social care needs are met by the service. Looked at records that must be kept in order to comply with current legislation. Checked that the staff of the service had the knowledge, skills, competency, experience and training to meet the needs of the people in their care. Looked around the building to make sure it was well maintained, clean, safe and comfortable for the people who live there and for the staff who work in the home. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 7 Checked what improvements had been made since the last inspection. Before the inspection we sent our questionnaires to the people who use the service, relatives, staff and healthcare professionals to complete. What the service does well: Elmstead provides a safe, caring and secure environment to their Service Users, treating them with dignity and respect and delivering person centred care. Elmstead is a comfortable, safe, warm and friendly environment; the home is well maintained, decorated and furnished to a good standard. The management and staff have an empathy with the people in their care, this was evidenced by the interaction between the management and staff team with the people who use the service; this was observed when walking around the home talking to the people who use the service and their visitors; the questionnaires received also stated that they “always receive the care and support they need” that the staff are “available when they need them” and that the staff “listen to them and act on what they say”. The following shows what the service does well ,ensuring that the people in their care receive a good standard of care making sure that their assessed personal, health and social care needs met:• The QUEST assessment and Personal Care Planning programme includes specific sections on resident choice. • QUEST is focussed on personalised care and increased opportunities for resident involvement on choice. • The Personal Best programme aims to ensure the views of the people who use the service are always at the forefront of the care provided • The organisation conducts annual Customer Satisfaction Surveys both internally and externally. • Complaints and compliments policies and procedures. • Resident / Relative meetings Bi-annually. • Monthly Reg 26s include discussions with residents and relatives. • Comments and suggestion forms are available in reception and Thank You forms which promote Personal Best. The home manager has an open door policy for the people who use the service, their relatives and the staff of the home, thereby ensuring consistent communication enabling any concerns raised to be resolved quickly and to the satisfaction of those involved. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: The Home Manager is aware of the need to maintain and improve the communication that has been effective with those who have contact from external providers and to maintain community links with those established over the last year. The Home Manager is continuing to improve the following concentrating on providing the best possible care for the people who use the service by focussing on the following areas and making sure that they are implemented:• • • • • • • • Rigorous recruitment policies and procedures. Care is more person centred. Diversity training on request. The Menu Manager programme provides help with developing meals for different dietary needs. Staff are supported where residents make inappropriate remarks Ongoing training. Regular reviews of policies and procedures. Personal Plans being regularly monitored with a specific view to equality and diversity. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 9 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 10 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 Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. (Please note that standard 6 is not applicable to this service.) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use this service and their relatives receive good quality information about the services offered by the home; enabling them to make an informed decision about whether or not the service can meet their assessed personal, health and social care needs. Prospective residents have their personal, health and social care needs competently assessed prior to moving to the home ensuring that the service can meet their needs respecting their wishes and preferences. All the people who use this service have a written contact with the home ensuring that they are clear about the terms and conditions of their residency. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 12 EVIDENCE: Since the last inspection the Home Manager has reviewed and update the Statement of Purpose and the Guide for the people who use the service. These documents are written in a style that is easy to understand, in plain english and are clear and concise in content. These documents provide comprehensive written information to all prospective individuals who wish to use the service and their relatives/representatives, outlining the ethos of BUPA Care Homes and the home, as well as vital information to help with the process of choosing a care home; thereby making sure that the service can meet their assessed personal, health and social care needs. It was evident from speaking to the people who use the service and their visitors, and from the questionnaires received, that they had access to enough information to help them decide if the home was the right place for them, before they move in. The people who use the service said that they were involved in the assessment process and that their wishes and preferences were taken in account. They also said that they felt the staff employed had the necessary experience, skills and competency to meet their assessed personal, health and social care needs. Four care plans were seen at the home; all these files had evidence of preadmission assessments being undertaken by, in most instances, the home manager or a member of the senior care staff; people referred by the local social services had a copy of an assessment of need completed by social services as well as an assessment done by the home Questionnaires received confirmed that the people who use the service and their relatives felt that the home met their needs well and that they received the care and support they needed; that the staff were always around to help them and nothing was too much trouble and that they were happy with the care they received. The people who use the service have a contract with the organisation detailing the terms and conditions of their accommodation including the cost, services provided and details of the accommodation; this contract included details of the role and responsibility of the provider and the rights and obligations of the individual. Copies of the homes’ reports, the Statement of Purpose are available in the reception area along with information appertaining to the organisation including details of other BUPA homes in the area, encouraging people to look at other homes so they are able to make and informed decision about the home. BUPA,s “Choosing a Care Home” brochure is provided along with “Paying for a Care Home” and the homes’ “Flexible Day Care Service” leaflet is available. Prospective residents who are unsure about the home and services provided are invited to have a trial in the home, to ensure that their needs can be met and that they would feel happy and content in the home All staff undertake enquiry training and to make sure of the quality of information given, regular mystery shops are conducted to ensure the home is Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 13 providing the correct information to enquirers. An open door policy is in place to allow visitors to see the home at their convenience. Day trials and assessments are encouraged which incorporates a meal time. Enquiry forms are completed and forwarded to other BUPA Care Homes if relevant. All visitors are invited to view the home at their convenience with protected meal times if possible. There was evidence that some of the people who had come into the home for a respite stay had decided to remain in the home rather than return to their own home; feeling they could enjoy the rest of their life being looked after in a good home. Please note that Standard 6 is not applicable to this home. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans reflect the assessed personal, health and social care needs of the people who use the service; ensuring that staff have the necessary information to give the care as to the wishes and preferences of the person. Information is agreed with the people using the service and if appropriate their relatives and advocates thereby ensuring the rights of the person, relating to choice, dignity, privacy and independence. EVIDENCE: Four care plans were looked at during the inspection, all care plans had been completed by using the QUEST care planning system that had been in Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 15 operation since the last inspection in 2007; the system is good and is person centred giving clear information as to how the person living in the home wants his/her care to be given respecting the wishes and preferences of the individual ensuring their choices, privacy, dignity and independence is respected at all times. The plans have been updated to include information relevant to the individual in respect of the Mental Capacity Act which is now current legislation. All plans include information relating to an individual assessment that is updated every six months; an essential lifestyle plan; the map of life; GP and hospital consultant, physiotherapy, speech and language therapist, district nurse, tissue viability nurse, continence nurse, podiatry, dietician and dental appointments and input; a personal plan including risk management; maintaining a safe environment including the persons mental state, cognition, waterlow, falls risk assessment, bedroom health and safety checklist and moving and handling risk assessment; breathing, eating and drinking, and night time care; eliminating, personal cleansing and dressing, nail care; controlling body temperature; pain medication; end of life, personal needs, expectations and/or medical conditions; relatives comments; and daily life. Care Plans produced with the help of the QUEST assessment tool, which are reviewed monthly and updated as necessary. It was evident from looking at one of the care plans that staff record and report on the treatment of pressure ulcers, as well as assess and document actions taken to alleviate the risk. All of the people using the service have their nutritional needs assessed using a recognised nutritional assessment tool; they are also registered with the GP of their choice however the home does have access to GP services locally and can offer this service to the people who live in the home should they wish. It was evident from looking at the care plans that they were personalised to the individual and that correct referrals were made via the GP surgery relating to accessing the services of other healthcare professionals. The medication system was checked and found to be accurate in documenting and recording medication administered to the people living in the home. MARS sheets were checked, they were dated and signed correctly and accurately, all had a photograph of the person and there was a copy of the homes, policies and procedures relating to the safe administration of medication. Monthly audits are conducted by the Regional Manager assessing many aspects of care to allow continual quality assessment and improvement. This is in addition to the Reg 26s and also detailed audits on specific aspects of care done at Home level (medication, Care Planning etc). A regular overview on the quality of resident care is provided by the Regional Manager, Regional Director and the Quality and Compliance team. The Key Operating Guides have been developed to ensure best practice in selected aspects of care, giving the required information at point of delivery. There are comprehensive policies and procedures which are regularly reviewed. Staff medication training is supplemented by NPA Accredited training provided by our pharmacist. Personal Plans are reviewed monthly and updated accordingly. Documentation audit records are maintained and incorporated into the monthly Reg 26’s. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 16 Medication audits are conducted monthly and incorporated into the Reg 26’s; specific time is allocated to allow completion of all necessary audits and documentation and the home manager is aware of the need to maintain staff levels and training to provide person centred care QUEST and Medication audits show an improvement, each Unit now has an independent clinic room, medication policies and procedures have been updated and records of medication have been reviewed and updated. The QUEST 2 care planning system has been implemented in the home, and staff have updated Personal Plans for QUEST 2. Monthly audits are conducted to ensure that the needs and preferences of the people who use the service are up to date. The keyworker system is in place; and the permanent staff levels have significantly increased providing a better continuity of care to the people who use the service The home manager is to consult with the local GP and Practice Manager to regularly review medication prescribed to the people who live in the home and of those who come to live in the home. Whilst walking around the home, from speaking to the people living there and from the questionnaires received it was evident that there was empathy between the staff and the people living in the home; staff spoke to them respecting their rights to privacy choices, dignity and independence. People living in the home said that they had confidence in the ability of the staff to look after them properly, that they trusted them with all aspects of their personal care saying they were gentle and caring and knew what they were doing. Staff spoken to, were aware of the Data Protection Act and the need to safeguard the confidentiality of the people living in the home. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided good quality and appropriate activities for the people living in the home; they are supported and encouraged to maintain a good quality of life within the home doing things they like enabling them to satisfy their social, cultural, religious and recreational interests and needs. The people who use the service are provided with good quality meals, that are nutritious, wholesome and healthy; meals are served as to the individuals choice, at convenient times to them and in pleasing surroundings. EVIDENCE: The service ensures that all the people who use the service have personal care Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 18 plans that are individual and based on their choices and preference; should they choose to do so, the people who use the service are encouraged to handle their own finances; personalise their bedrooms with photographs, pictures, ornaments, televisions, music systems and small items of furniture important to them thereby giving them somewhere they can really feel at home. The home manager has implemented an open visiting policy enabling people to visit when it suits them. The chef manager at the home has been instrumental, in conjunction with the home manager, in developing menus that allow for resident choice and preferences; the Menu Master helps to ensure that every menu within the home is customer led and nutritionally balanced. The ‘Nite Bite’ menu allows the people who live in the home to choose what to eat when they feel like it, providing healthy choices at any time through the night, the people who use the service and the staff of the home are encouraged in the development of the menus. The homes’ kitchen has been awarded the Clean Food Award form London Borough of Bromley Environmental Health and is on display in our Reception area; having been awarded five stars from the food standards agency; compliments on the visitors meal scheme indicate the success of this. All residents are weighed and their BMI calculated monthly. Chef Manager takes an interest in the residents diet and works alongside the care staff to monitor any changes. The Menu Manager is implemented to ensure that Service Users receive a choice of a nutritionally balanced menu. A Compliments and complaints book specific to catering is available on each unit to assist with communication, highlighting requests, which is looked at daily by the Chef Manager The service has a structured activities programme, with a dedicated Activities Organiser, there is also a weekend activities programme. Relatives and friends are encouraged to have a meal at the home with their family and are invited to larger/group activities. Since the last inspection a sensory garden has been developed to stimulate and provide additional activities; the home also encourage local groups to visit and entertain ie: gospel choir, Pat-a-dog. The home has been recognised for the excellent care that it provides by being awarded the in-house award for Service Excellence, proudly displayed in the reception area; activity records are kept of activities undertaken to ensure that the preferences are met and recorded in the Personal Plans; requests are listened to and the activities co-ordinated effectively; the home maintains community links with the local church, school, and encourages local residents to visits to events such as “Community-tea”, Open Day. The home manager in consultation with the activities co-ordinator, the people who use the service, their relatives and the staff of the home is endeavouring to increase the number of outside visits to the theatre, shopping, cinema and trips to places of interest and the countryside and coast. And to be able to overcome the restraints that are evident with outside ventures; also to look at a wider range of activities that are more focused on the individual; to try and encourage relationships between the people who live in the home, to encourage them to interact more with the staff in the home and with those who visit the home. Joined NAPA and have a membership with them. An increase in the staff levels Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 19 Has facilitated the redistributing some of the tasks, leaving more time for the staff to focus on the people who live in the home and their activities, thereby stimulating the individual more during daylight hours to help and encourage restful sleep during the night. The home manager is to increase staff levels during the day to allow more time for person centred care; and is to create a vegetable garden and encourage participation from the people who live in the home and maybe to use some of the produce grown in the kitchen. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in the home are able to feel safe and protected in the home due to the organisations policies and procedures relating to complaints, safeguarding of vulnerable adults, recruitment and selection and staff training. The people who live in the home can be assured that the home protects their legal rights as stated in their Statement of Purpose. EVIDENCE: BUPA Care Homes is currently reviewing its current complaints policy. The home has a complaints policy and procedure that complies with the National Minimum Standards; this document forms part of the homes’ Statement of Purpose; and is included in the Service User Guide given to Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 21 every service user in the home. The complaints policy and procedure is also displayed in all communal areas throughout the home. The home maintains a complaints log; complaints are initially investigated by the home manager and the outcome communicated to the complainant. On speaking to the people who live in the home and from surveys completed, they confirmed, that they knew how to complain, and if they were unhappy or if they had any concerns about anything in the home; they said that they usually approached the care manager of their unit about any concerns they had and said that they were dealt with and resolved quickly The current policy has agreed timescales for managing complaints; the information that accompanies the policy is prominently displayed in the home. The policy includes a three – tier framework including the home, the regional management team and the National Quality and Compliance department of the organisation. The open door policy adopted by the Manager ensures that the people who live in the home, their relatives, staff and visitors can address issues directly if required, and there is a designated person in charge of each shift to effectively handle any matters that may be of concern. Effective communication between the home, the people who live there and their relatives enables complaints to be kept to a minimum; relations have been strengthened between staff, the people who live in the home and their relatives making sure an open and honest approach has been established, and the home manager ensures that the open door policy continues. The home displays information about advocacy services within the local area and is able to access the service on behalf of residents who do not have any next of kin to manage their own affaires. The people who live in the home are encouraged and supported to vote in general and local elections either by visiting a local polling stations or applying for a postal vote. The home has a robust policy and procedure relating to the Protection of Vulnerable Adults; in conjunction with the Local Authority Guidelines; both these documents are available to staff and staff also confirmed that they have completed training courses about these issues. BUPA Care Homes has robust allegation of abuse and neglect policies, allowing staff to raise any concerns they may have within the home or to senior staff outside the home. The staff have access to the organisations policies and procedures relating to the Safeguarding of Vulnerable Adults and are able to refer to them at all times. The home also has a robust policy and procedure around “whistle-blowing where staff making an allegation can feel save and protected, as the organisation has a national team of Quality and Compliance experts available to provide advice and help where needed, specialist training is available to all staff regarding to all aspects of protection policy reminders are available for all staff and regularly handed to them individually Staff interviewed during the inspection showed an understanding of how an allegation of abuse is taken forward using the homes’ policy and procedure and t Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 22 the London Borough of Bromley Guidelines; they were also aware of how to instigate the “Whistle-blowing” policy and procedure. . Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live in the home experience a well-maintained, well decorated and furnished, spacious, clean and hygienic house; the home is able to encourage and support their independence by making sure that the layout and design is appropriate and safe for the people who live there. EVIDENCE: During a tour of the home it was evident that the home was clean and tidy, pleasant and hygienic creating a homely environment for the residents and their visitors. The homes’ high standard of cleanliness is the work of a Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 24 dedicated team of housekeeping staff who maintain the standards expected by the people who live and work in the home; the domestic team use a specialist microfibre cleaning system that combined with effective and efficient cleaning regimes keeps the home clean and odour free. This group of domestic staff is trained to NVQ standard and have all undertaken COSHH training and training in infection control. The residents and relatives surveyed agreed that the home was always fresh and clean. The laundry facilities in the home are good, the laundry is well organised and the residents clothing and the linen used in the home were in a good state of repair; the laundry person spoken to was aware of the homes’ policies and procedures regarding the laundry and confirmed that she had COSHH and infection control training. The washing machines, dryers and ironing equipment were all in working order. The laundry bags used were colour coded and disposable bags were available for infected laundry. he organisation comprehensive policies and procedures I relating to the health and safety of the environment including infection control, the handling clinical waste, services and facilities comply with the Water Supply (Water Fittings) regulations. The Home is supported in maintaining the environment by a central department that has a specialist Property and Estates department as well as a Hotel Services department and Regional Managers visits focus on the standard of housekeeping during regular visits to the home; this has resulted in the home gaining a 5* rating awarded by the EHO. A homely environment is encouraged and Service Users are encouraged to personalise their rooms as they wish with any personal items they have. It is often commented that the home is clean, tidy, odour free and a nice place to live, resident surveys indicate that the people who live in the home find the cleanliness important and that we deliver this. Some of the furniture and furnishings have been updated in line with the annual refurbishment plan to modernise the interior of the home; the home manger has done some research and as a result of this has added some bolder colours and signs to the dementia unit enabling the people who live their to recognise areas more readily for example the toilet and bathroom doors. Since the last visit to the home; two new fitted bathrooms and a wet room for showering have been added to the facilities available. The home has nine ensuite bedrooms, the rest of the bedrooms share the toilet and bathroom facilities; the facilities seen were in a good state of repair, well equipped with hoists, parker baths and toilets had raised seats and grab rails. Bathrooms and toilets were maintained to a good standard and kept in a clean and hygienic condition. The bedrooms seen in both the residential units and the dementia unit are well decorated and the furniture and soft furnishings were of a good standard; the rooms had been personalised by either the resident or their family and the rooms contained small items of furniture and ornaments, photographs and pictures; many of the residents had their own televisions, music centres and radios. Residents and visitors spoken to said that they were encouraged to bring their personal belongings into the home and said that it helped them to “settle in” and feel more “at home”. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 25 The activities area has been improved and is widely used. Staff facilities have improved. A Sensory Garden has been created and additional activities are held in the garden during fine weather. The Day Centre space is used for group and larger activities and holds concerts and shows arranged by staff. A gardener has just been allocated to upkeep the grounds more effectively A refurbishment of the Home is due in 2009. This will allow for a small but private day room on the ground floor and a larger, modern hair salon on the mezzanine floor. New lighting is scheduled for the communal areas. A vegetable garden is to be created, to allow for additional stimulation and activities for the people who live in the home. Elmstead DS0000006930.V376191.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home endeavours to ensure that staff team are able to meet the personal, health and social needs of the service users; this is achieved by implementing the organisations stringent recruitment and selection policies and procedures, and by implementing a good induction training programme complemented by additional mandatory and specialised training to update staffs skills. EVIDENCE: BUPA Care Homes has comprehensive Human Resource policies and procedures to aid staff management and recruitment. Three personnel files were examined during the visit to the home, the files were well organised and the documentation was all in order; there was evidence of POVA and CRB checks being completed and recorded on file. All the files seen contained an application form with an employment history, two references from previous Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 27 employers, a medical questionnaire, details of the interview, evidence of identity, a photograph, evidence of induction , mandatory and specialist training and details of being mentored by a senior staff member and documentation completed when shadowing an experienced staff member. The home manager maintains agreed staffing levels at all times, this was evidenced from the copies of four weeks of rotas given at the inspection and checked. There is a training matrix specific to the Home that identifies the training requirements of staff; it was noted that mandatory training is up to date as is specialist training particularly around the Safeguarding of Vulnerable Adults, Dementia, Challenging behaviour, Mental Capacity Act Awareness and Personal Best. This has gone a long way to improve the skill mix of staff employed, their competency and experience making sure that they are able to deliver good care to the people they care for in the home. BUPA Care Homes has received IIP accreditation and it has been reviewed since 2003. There has been no usage of agency staff this year, the home manager has set up a regular team of bank staff to cover any permanent staff absences; all recruited bank staff have positive references and POVA checks prior to induction and CRB checks are undertaken, this step has helped with the retention of staff and has enhanced the continuity of care for the people who live in the home. Staffing levels have been increased to relate to the needs of the people who use the service and the environment. Agency usage has been zero this year to date. More staff have been placed on the NVQ programme, and the Personal Best programme has been fully implemented showing recognition of the work done by the homes’ staff; employee of the month has been introduced to help motivate staff and promote teamwork; to enhance staff numbers the home manager has invited volunteers to join the team Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 28 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The organisation has appointed a manager who has been in post since 2007; she has the experience, skills, qualifications and competency to manage the home in an effective and efficient way; safeguarding the people in her care and her staff team. The home manager has an open door policy and an honest, transparent style of management; the people who use the service, their relatives and the staff of the home agreed that the manager is approachable and is happy to listen to any issues and concerns they may have and tries to resolve them as quickly as possible. The staff are appropriately supervised and have an annual appraisal ensuring their skills, competency and training are updated regularly making sure they are able to deliver good quality care to the people who live in the home. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 29 The home has effective and efficient financial, administrative and health and safety systems in place ensuring the stability of the home and safety of the service users, their relatives and staff. EVIDENCE: Regular Health and Safety meetings take place, with a standardised agenda giving staff the opportunity to communicate on Health and Safety issues; the minutes from these meetings go to the Regional Manager and Quality and Compliance team; where there are regional and national experts available within the company for advice and guidance if required. The Home is supported by a national team of Quality and Compliance Officers whose role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. There is a dedicated team of Health and Safety staff within the regions, supported by a National Quality and Compliance team; this includes Health and Safety and Fire Management Leadership. BUPA Care Homes has a comprehensive suite of policy and procedure manuals that are regularly reviewed by experts and updated when required. We have an annual internal and external Customer Satisfaction Survey. BUPA SOP (Surveying Our People) is conducted annually; the results of the survey undertaken in 2008 are as follows:Overall Service - 73 Staff overall - 96 Food overall - 84 Treats you as an individual – 88 Activities overall - 92 Buildings & surroundings - 84 Own room - 80 Communal Rooms - 89 The Personal Best programme encourages a person centred approach to all tasks. All staff are supervised on a regular basis and there is an annual appraisal; evidence of supervision and appraisal was found in the personnel files seen and confirmed by staff spoken to during the tour of the home. Meetings are held and recorded. A Health and Safety Committee consisting of the home manager and staff of the home is in place all minutes are passed on Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 30 to the Regional Manager and Quality and Compliance team, mandatory paperwork is kept up to date and filed. Risk assessments are reviewed and being updated. An in-house banking system to ensure the safe keeping of residents funds, allowing them to remove amounts as and when required; records are available upon request by the person living in the home. The home manager ensures that all items in meetings are discussed and acted upon where applicable The Home Manager has been successful, she is proving to be an asset to the home; the people who live in the home, their relatives and the staff of the home said that she is approachable and always ready to listen to their concerns and acts upon them thereby ensuring that the problems are resolved quickly and to everyone’s satisfaction. Teamwork has been enhanced due to staff rotation to ensure an all round knowledge of the Home and of the people who live in the service. The QUEST 2 care planning system has been fully implemented. The home manager is looking into the possibilities of management and staff attending training courses and Local Authority forums to enhance and update their skills and competency; also providing information about innovations in the public care sector. Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 31 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 4 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 3 3 3 3 3 3 4 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 4 3 4 3 3 3 3 3 Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 32 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elmstead DS0000006930.V376191.R01.S.doc Version 5.2 Page 33 Care Quality Commission London Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.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. 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