Care Home: Elsenham House Nursing Home

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What the care home does well People thinking of moving into the home were given useful information to help them to make a decision about whether it was the right place for them. The manager and lead nurse carried out an assessment with new people to make sure that their needs were fully understood and could be met at Elsenham House. When asked what the service did well, a member of staff wrote, "Provides a warm, caring environment in which the residents feel confident and respected." Residents told us they were satisfied with the lifestyle offered in the home. One said, "They make us feel at home." There were no obvious restrictions on residents and most were able to make decisions about what to do with their time. Staff supported them to take part in activities that helped with personal development and make good use of leisure time. One resident who returned a survey told us that the activities were very good. Residents were encouraged to move toward independent living when they were ready. There was a clear complaints procedure. It explained who residents could speak to if they were unhappy. The home had not received any formal complaints since our last inspection. Elsenham House provided a homely and comfortable environment. Residents were supported to make their bedrooms into their personal space and most rooms reflected the interests and lifestyle of the occupant. Everyone we asked told us they liked their bedrooms. What has improved since the last inspection? New staff had all the required information and documents on their personnel files to evidence that appropriate pre-employments checks were carried out. The staff rosters had improved and they showed a clear record of which staff were on duty at any given time. This included the times when the registered manager worked in a hands on capacity in a care assistant role. Pre-admission and ongoing assessments were clear and informative, which helped staff to identify residents` needs and abilities. What the care home could do better: Although there was a new care planning system in place, the content of the care plans and associated records were still not detailed enough to ensure that people were supported consistently and in the way they wished. Plans to assist people to meet their physical and mental health needs were not informative enough. The information in care records was not always current and up to date. Care plans were not always read by staff, which could result in staff missing out on information about new residents or those with changing needs. There must be risk assessments and management plans to support people who may encounter risks to their health or safety when going out in the community, either alone or with staff. Medicines management must be further improved to ensure that practice is safe and residents receive their medication as it is prescribed. The systems for monitoring the quality of the service should be further developed to ensure there is a cycle of audit, planning and development. Residents should continue to be involved in the process to ensure they have a say in how the service progresses. Key inspection report Care homes for adults (18-65 years) Name: Address: Elsenham House Nursing Home 49-53, 57 Station Road Cromer Norfolk NR27 0DX     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jane Craig     Date: 2 3 0 3 2 0 1 0 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 35 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 Adults (18-65 years) 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. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 35 Information about the care home Name of care home: Address: Elsenham House Nursing Home 49-53, 57 Station Road Cromer Norfolk NR27 0DX 01263513564 01263511511 elsenhamhouse@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Elsenham House Ltd Name of registered manager (if applicable) John Dupuis Type of registration: Number of places registered: care home 31 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: One named service user over the age of 65 may be accommodated. Date of last inspection Brief description of the care home Elsenham House is situated in an urban location, on the outskirts of Cromer. It comprises four properties, divided by one house in between. The first three properties were built in approximately 1890, they have small rear gardens where there are lawned areas and patios for Service Users use. Public transport services include a bus service every 15 minutes and a train service from Cromer every 20 minutes. Fiftyseven Station Road, Cromer, the fourth property, is intended as a unit where Service Users are encouraged to develop their skills and become more independent, prior to moving back into the community. Many of the service users are encouraged to be as independent as is possible and are facilitated to continue to engage in activities outside Care Homes for Adults (18-65 years) Page 4 of 35 Over 65 0 31 0 2 0 7 2 0 0 9 Brief description of the care home the home and work experience. Information about the service, including the range of fees and extra charges, is available from the manager. Care Homes for Adults (18-65 years) Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection on this service was completed on 2nd July 2009. This key (main) inspection includes information gathered since the last inspection and an unannounced visit to the home. The visit was carried out over two days on 17th and 23rd March 2010 by two regulation inspectors. The inspection of the medication standard was conducted by the Commissions pharmacist inspector on 23rd March 2010. At the time of the visit there were 25 people resident in the home. We met with some of them and asked about their views of Elsenham House. We spent time observing daily routines in the home and how staff interacted with residents. Four residents were case tracked. This meant that we looked at their care plans and other records and talked to staff about their care needs. Care Homes for Adults (18-65 years) Page 6 of 35 We talked to the registered manager, the lead nurse and several members of the staff team. We looked around the three houses and viewed a number of documents and records. As part of the inspection process we sent out surveys to a random selection of people living and working at the home to gain their views about various aspects of the service. We had a good response from both groups and information from surveys has been taken into account when making judgements about the service. This report also includes information from the annual quality assurance assessment (AQAA), which is a self-assessment report that the manager has to fill in and send to the Commission every year. Care Homes for Adults (18-65 years) Page 7 of 35 What the care home does well: What has improved since the last inspection? What they could do better: Although there was a new care planning system in place, the content of the care plans and associated records were still not detailed enough to ensure that people were supported consistently and in the way they wished. Plans to assist people to meet their physical and mental health needs were not informative enough. The information in care records was not always current and up to date. Care plans were not always read by staff, which could result in staff missing out on information about new residents or those with changing needs. There must be risk assessments and management plans to support people who may encounter risks to their health or safety when going out in the community, either alone or with staff. Medicines management must be further improved to ensure that practice is safe and residents receive their medication as it is prescribed. Care Homes for Adults (18-65 years) Page 8 of 35 The systems for monitoring the quality of the service should be further developed to ensure there is a cycle of audit, planning and development. Residents should continue to be involved in the process to ensure they have a say in how the service progresses. 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. Care Homes for Adults (18-65 years) Page 9 of 35 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admission process ensured that people had enough information to make a decision as to whether the home was suitable to meet their needs and staff had sufficient information to be able to confirm that the persons needs could be met. Evidence: People who were thinking of moving into the home were provided with a service users guide and there was a copy in every bedroom for residents to refer to. Everyone who returned a survey indicated that they had a choice about moving into the home and they had received enough written information to assist them to make this decision. Prospective residents were encouraged to visit Elsenham House. The annual quality assurance assessment (AQAA) told us that the service provides an exceptional level of trial visits, which included the opportunity to participate in activities and outings with the current residents. One resident we spoke to said he had looked at about five other places before deciding Elsenham House was the right one. Anyone referred to the home was assessed by the manager and lead nurse before the Care Homes for Adults (18-65 years) Page 11 of 35 Evidence: placement was confirmed. This practice helped to ensure that the persons needs were understood and could be met by the service. The registered manager advised that, where possible, they obtained supporting information from health and social care professionals. However, most of the recent admissions to the home had been on an emergency basis and as such this information was not always available until after the person had been admitted. The examples of the assessments we saw looked at the persons strengths and needs in activities of living, health and behaviour. They provided staff with sufficient information to be able to draw up initial care plans. The manager discussed how some residents moved on from the main house (number 49/51) to 53 and 57 as their need for support changed to focus more on rehabilitation. Some of the residents we spoke to had made this transition and were happy with the way they were supported. Care Homes for Adults (18-65 years) Page 12 of 35 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care planning process was not thorough enough to ensure that staff had sufficient information to support people to meet their needs in the way they preferred. Evidence: The new care records, which had been introduced at the time of our last inspection, were in use for all residents. Each of the people we case tracked had a recent assessment, which highlighted areas where they needed a care plan. The assessments were clear and informative. However, with a few exceptions, the care plans lacked information about the individual and how best to support them. There was a lack of, or, limited goals. Most plans did not give staff sufficiently clear directions to ensure that they provided consistent care. For example, one care plan indicated that the resident made accusations but there was a lack of directions to ensure that all staff dealt with this in the same way in order to protect the resident and themselves. Residents had opportunities to be involved in drawing up their care plans if they wished and some had signed their agreement to plans. Care Homes for Adults (18-65 years) Page 13 of 35 Evidence: The frequency of evaluations of care plans varied. Some were evaluated when the person was re-assessed. Others had not been reviewed for over a year and we were told that some directions were no longer applicable, even though the plans were still in place. The care records of the people we case tracked included a number of documents that were not relevant and were only partially completed. This made files cumbersome and difficult to understand. We discussed with the manager about reviewing the design and layout of care files to make them more accessible to residents and staff. There were some good examples of plans to assist with complex behaviour. For example, one person had a clear plan to support them when they became aggressive. It included warning signs and told staff what strategies had helped in the past. However, this was not consistent. One person who was assessed as being medium risk of violence did not have a corresponding plan and their assessment had not been reviewed for six months. One of the residents was subject to restrictions under the Mental Health Act. There was no evidence to show that the persons rights had been explained to them. There was also a lack of information or care plan to ensure that all staff were completely aware of the persons rights or their own responsibilities. The majority of staff who completed surveys indicated that they always received up to date information about the needs of the people they cared for. However, a number of staff we spoke with said they had not read the care plans and they relied on information given to them during handovers. Reliance on verbal communication could potentially increase the risk of misinterpretation and misunderstanding. One staff member acknowledged that the verbal reports usually only included what had happened over the previous few shifts and were not always useful for staff who had been away for any length of time. Two members of staff confirmed that they did not know how to support a particular resident who had a history of aggression. Some of the assessments we saw included a judgement about whether the resident had the capacity to make decisions about their daily life. People who were able to make decisions were supported to do so. Most residents who returned surveys indicated that they could make decisions about what they did each day. One resident told us, I like that I can come and go. There was evidence on files that residents who needed assistance to make decisions were referred to advocacy services. Care Homes for Adults (18-65 years) Page 14 of 35 Evidence: Some people managed their own money. Others had assistance from staff, sometimes in the form of a daily budget. One of the care plans we looked at directed staff to limit the residents money to a daily allowance. There was no specific financial plan, which had been agreed by the resident. Another resident had two care plans with regard to managing their finances but these contained conflicting information and it was not clear which plan was to be followed. Each resident had risk assessments on their files, which identified some of the risks to their own and other peoples safety. There were some good risk assessments and management plans, for example, with regard to smoking and complex behaviour. However, there was a lack of assessments relating to residents safety when going out, either alone or with staff. This meant that any potential risks, such as those relating to street crime or traffic, might not be highlighted and controlled. In addition, there were no formal risk assessments of peoples safety to use equipment or appliances when they moved on to 53 or 57, where there was a greater focus on carrying out domestic tasks. Care Homes for Adults (18-65 years) Page 15 of 35 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home received the support they needed to lead their chosen lifestyle. Evidence: Several residents who returned surveys and those we spoke to, made positive comments about the service and told us they were happy with their lifestyle. One person wrote, They make us feel at home. Another told us, Its the happiest I have been for years. A resident who had been accommodated in several similar services said, Without doubt this is the best place I have ever been. During the course of our visit we observed that routines were relaxed. Most residents who completed surveys indicated that they were able to do what they wanted to. People who were able to, organised their own time. Those who were safe to do so went out alone and pursued their own activities. A resident told us that he went out Care Homes for Adults (18-65 years) Page 16 of 35 Evidence: most days into town or to Norwich and came back in the evening. Residents were supported to be as independent as possible. The manager told us that staff also understood which residents needed more staff input for longer because they became stressed and at risk of relapse, especially if they felt they were being moved towards independent living too soon. There was very little written information about residents life histories and none of the people we case tracked had recorded goals with regard to personal development, or how they spent their time. Despite a lack of written programmes, residents were supported to take part in various activities both in the house and in the local community. They could attend courses for personal development if they wished to. For example, the AQAA told us that one person was learning a language and another was hoping to undertake a university access course. Residents, especially those accommodated in number 53 and 57, were supported to undertake domestic chores to help them to move towards independent living. There was also a wide range of leisure activities on offer. One resident told us that he went to football matches. When asked what the home does well, one person who returned a survey wrote, Doing different things like horse riding, going to the cinema and other things. Another wrote that the trips out were very good. On the day of our visit a group of residents from across the houses were going out to have a ten pin bowling competition. Some of the staff who returned surveys also commented that activities was something the home did well. There were no restrictions on visiting. The AQAA told us that residents were able to entertain friends and relatives at the house. People were also supported to visit their friends and family. One person said that staff took them every few months to see their family. Another person told us that she regularly visited her fiance and he also came over to Elsenham House. Several residents who completed surveys and those we spoke to commented that they liked the meals. They were given a choice and residents could have an alternative if they did not want the planned meal. People who were moving towards independent living shopped for and cooked their own meals, under the supervision of staff. The residents had input into the menus and cooked on a rota basis. Meals for residents living at 49-51 were prepared in the main kitchen. Although there were set meal times, residents told us they could have one saved if they were going out. On the day of our visit the midday meal looked appetising and everyone we asked said they enjoyed it. Snacks and drinks were available throughout the day. The home received 5 stars after their last environmental health inspection. Care Homes for Adults (18-65 years) Page 17 of 35 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of consistency in health and personal care planning and shortfalls in the management of medicines could compromise peoples safety and result in their needs not being met. Evidence: The AQAA told us that the staff team respected residents preferences with regard to their personal hygiene routines. There was an acknowledgement that some people preferred a structured approach and others were more easy going. However, most plans to assist people with personal care were not sufficiently detailed to ensure that staff provided support in the way the person wished. For example, several directed staff to prompt or encourage people but there was very little information about the persons individual needs and abilities, their preferred routines or how they wished to be supported. A member of staff told us they thought there should be an accessible care plan for how care assistants work with the person because it is currently passed down by word of mouth. Some plans to assist with personal care were clearer, for example, plans to assist with continence needs. We found information about residents medical history on their care files. There were Care Homes for Adults (18-65 years) Page 18 of 35 Evidence: care plans to monitor ongoing physical health care needs but these were not always sufficiently detailed. For example, one person had a care plan relating to their diabetes, which gave staff clear instructions about some aspects of their care. However, two staff told us the resident exhibited certain behaviour when their blood sugar was unstable but this had not been written into the plan to ensure that all staff were aware of what to look for. Another resident had a care plan which listed their physical illnesses but there was no information about how they affected the person, what staff should look out for, or what they should report on. Care plans relating to mental health needs were generally more informative but some still lacked evidence of therapeutic interventions. For example, a plan to support one resident who had paranoid delusions did not include any information specific to that person. One of the directions to staff was to reassure the person but was not clear about what usually helped. Care plans for physical health needs were not always followed. One person had a plan to support them to lose weight. There was a measurable, monthly goal but the person had not been weighed for six months. Another plan indicated that the person needed to have their blood pressure checked each week but the last recorded check was in October 2009. There were assessment forms for staff to monitor risks to residents health caused, for example, by falls, poor nutrition or moving and handling. Where appropriate, these had been completed. Some residents told us that their mental health had improved since being at Elsenham House. One resident who completed a survey wrote, The nurses always help me all the time. There was evidence on care files that residents were supported to access health care facilities. New residents were registered with a GP and staff had taken one person for a check up shortly after admission. One resident told us that staff helped him to keep track of his appointments so he did not forget any doctors visits. Other residents told us they were supported to engage in physical activities which helped to promote health, such as attending the gym and going swimming. Residents were also offered support to stop smoking. The inspection of the medication standard was conducted by the Commissions pharmacist inspector Mark Andrews. During the inspection we looked at how the home is storing, administering and recording medicines. We also looked at associated records such as peoples care notes. We were informed that all medicines other than those held by people living at the Care Homes for Adults (18-65 years) Page 19 of 35 Evidence: home who are managing their own medicines are stored in the lower ground floor office in cabinets and a medicine refrigerator. Since the previous inspection new cabinets have been fitted in the medicine storage room. We looked at medicine refrigerator temperature daily records and with a few omissions noted that temperatures have recently been within the accepted range. The home has recently changed its pharmacy provider and has implemented a change of medicine monitored dosage system and medication charts. When we examined medication charts we found there to be a number of gaps in records for the administration of medicines including one for the administration of insulin to a person living at the service scheduled for administration the day before inspection. By these omissions it is not possible to determine with certainty if the medicines have been given and also safe medicine administration procedures have not been followed. We also noted that the home is still using the former coding system for the nonadministration of medicines and records are not in line with those codes specified on new medication charts. We conducted an audit of some medicines and found there to be a number of numerical discrepancies where medicines could not be accounted for and records did not demonstrate that they were being given in line with prescribed instructions. We found for example, that for a person prescribed an antipsychotic medicine there was a deficit of tablets which the senior registered nurse on duty was unable to account for. We asked the registered provider to investigate this discrepancy and report his findings and conclusions to the Commission in writing. We saw evidence that the home undertakes regular medicine stock counts and notes quantities of medicines brought forward to new 28-day medication charts however when we asked the senior registered nurse on duty about the level of auditing in place we established that the homes internal auditing is currently not sufficient to identify medicine discrepancies arising. We found there to be improvements in care plans in place relating to when medicines of a psychotropic nature are prescribed for administration at the discretion of nursing staff (PRN). We also found there to be records to support or justify their use. However, we found for one person that whilst the dose of such a medicine had recently been changed this was not reflected in their care plan and there was no guidance about when a higher dose can be considered for administration. We also noted that the home would benefit from having copies of such care plans placed alongside medication charts for easy reference. We attempted unsuccessfully to find records for the authorised dose change, however, a number of other interventions were recorded. Care Homes for Adults (18-65 years) Page 20 of 35 Evidence: There are several people at the home who have control of their own medicines and self-administer them. We looked at how the home is supporting these people to maintain independence with their medicines and noted that a minimum of once weekly records are being kept of staff supervision of peoples medicines. The senior nurse on duty said that the checks include monitoring peoples compliance with their treatments and that medicines are being kept securely. We also noted that people who are selfadministering their medicines have had re-evaluations of care plans and risk assessments in relation to their self-administration of medicines. The home is keeping weekly records of when they supply medicines. Care Homes for Adults (18-65 years) Page 21 of 35 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints and safeguarding processes in the home helped to protect people using the service. Evidence: There was a clear complaints procedure included in the service users guide and also on display in the house. The procedure included contact details of organisations residents could go to if they were unhappy with the response from staff. There had been no complaints made directly to the home since our last inspection. CQC had received correspondence about concerns relating to the care of one individual and we looked into these during our visit. All of the residents who completed surveys told us that they knew who to speak to if they were not happy and they knew how to make a complaint. Some of the residents we spoke to named members of staff they would feel comfortable talking to. Staff who filled in their questionnaires indicated that they knew what to do if anyone raised concerns to them. The staff we spoke with told us they had received training in safeguarding vulnerable adults. The training records were not completely clear about how often training was updated, to ensure that staff were kept informed about any changes in policy. Staff said they were aware of their responsibility to report harmful or abusive practices. They all said they would report any suspected or alleged abuse to the manager or to outside agencies if they thought it was not being dealt with. There was a copy of the Norfolk County Council safeguarding procedure for staff to refer to but the procedure Care Homes for Adults (18-65 years) Page 22 of 35 Evidence: specifically for the home was not clear enough and contained out of date information. Three referrals, relating to allegations of poor practice, were made to the safeguarding team since our last inspection. Two had been accepted and investigated under safeguarding protocols. One had concluded that there was need for changes in the way one person was being supported and these had been put into place. Some senior staff had received training about the Mental Capacity Act and related legislation and other staff were due to receive cascaded training. Residents general capacity to make decisions was assessed prior to admission and kept under review. The registered nurse then made a judgement as to whether an external assessment of capacity was necessary. Care Homes for Adults (18-65 years) Page 23 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Elsenham House provided people with a comfortable and homely place to live. Evidence: Elsenham House provides accommodation in three separate houses. At the time of our visit people accommodated in the main house (number 49-51) generally required more staff support and those in 53 and 57 were working toward more independent living. Each house had its own bedrooms, bathrooms, sitting and dining areas. The three houses were in a good state of repair. The AQAA told us that the manager carried out an audit of repairs and cleanliness every month. Redecoration and refurbishment were carried out on an ongoing basis and there were some safety measures such as window restrictors and valves on the hot water taps in bathrooms. However, there were no checks to ensure the valves remained functional. One of the bathrooms had a bath hoist to assist a resident who had reduced mobility. Each house had an outside shelter for smokers and there were signs all around to advise residents that they were not to smoke in their rooms. Despite these measures there was a smell of smoke in one of the houses. A number of the bedroom doors had door guards that were sensitive to sound, which Care Homes for Adults (18-65 years) Page 24 of 35 Evidence: meant they released when the fire alarm sounded. A resident in number 57 used a wedge to keep their bedroom door open when they were in the room. It was not clear whether it was being used at night, which meant that the door would not provide any protection in the event of a fire and present a greater risk to residents and staff sleeping in the house. The decor and furnishings in the communal spaces were comfortable and homely. We noted that most bedrooms were highly personalised and reflected the interests and lifestyle of the residents. Everyone we asked said they were happy with their bedrooms. One person said, I love my room, I did have a problem with storage but this has been sorted out. At the time of our visit the three houses were clean and tidy. Most residents living in 53 and 57 took responsibility for cleaning their own bedrooms and helped with the rest of the cleaning on a rota basis. Those residents we asked said they did not mind doing their own cleaning. Staff support was available for anyone who needed it. A domestic was employed to work in the main house. On the first day of our visit there was an outbreak of diarrhoea and vomiting affecting a number of residents and staff. The manager and lead nurse had informed and sought advice from external agencies and the infection was contained within a few days. There were appropriate hand washing facilities in each of the houses and staff were provided with gloves and aprons. Not all staff had received recent infection control training but in-house sessions were planned. There was a written procedure for staff to follow but it was not specific to the home, for example, there were no contact details for the local health protection agency or environmental health department. Care Homes for Adults (18-65 years) Page 25 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were supported by staff who received regular training and supervision, which helped to ensure that their needs were understood. Evidence: Staffing rosters showed which staff were on duty at any given time. From 8am to 6pm there were three care workers in the main house and a care worker each in 53 and 57. There were two nurses based in the main house but they also supervised the other staff and residents. From 6pm there was one nurse and one care worker working across the three houses. The manager also stayed on duty until 8pm for four days per week and assisted where needed. Number 57 was generally unstaffed during this period. Residents we spoke to were happy with this situation and told us that they could call for staff help at any time. There was an emergency call system linked to the main house and two residents told us that if they pulled the red cord someone would come. At night there was one nurse and one care worker on waking watch and a care worker sleeping in at number 57. There was an out of hours nurse on call. We were told they could reach the home in a matter of minutes. The manager and lead nurse confirmed that extra staff would be rostered if a resident needed extra support or there was an activity planned, which required more staff. Residents who we spoke to said there were enough staff to help them. One said, If Care Homes for Adults (18-65 years) Page 26 of 35 Evidence: you need someone there is someone there, even in the night. They said if they wanted to do something spontaneous like go for a walk there was always staff to help them. Staff who completed surveys had mixed views about whether there were enough staff to meet the individual needs of the residents. Most said there were usually enough staff and two commented that it depended on whether all the staff turned in. One member of staff commented that they did not think there were enough staff in the evening. At the time of our visit there were no obvious signs that there was a lack of staff to meet residents needs. However, because of the number of residents who had potential to exhibit aggression or other complex behaviours, the low numbers of staff in the evening could increase the risk of residents being harmed. Several residents complimented the staff team. One said, There is nothing better than the staff. Residents who completed surveys all indicated that the manager and staff treated them well and one person told us, The staff are all good, they treat you well and have time for you. We looked at the files of two recent employees. The files were organised and showed that the recruitment practices provided safeguards for residents. There were completed application forms and both applicants had attended for interview. There were set questions for registered nurses and care workers, which helped to ensure people were recruited with regard to equal opportunities. References and CRB disclosures had been obtained before the staff started work at the home. Written references were followed up with a telephone call to ensure they were genuine and accurate. The administrator checked that nurses had a valid registration before they started work and nursing staff were asked to provide proof of re-registration each year. The administrator carried out random checks to ensure that registrations were up to date. New care staff completed an induction training programme. Most staff who completed surveys indicated that their induction training had covered everything they needed to know in order to start work. The training programme covered the common induction standards recommended by the national training organisation. Staff completed workbooks and assessments for each topic. They had practical supervision with registered nurses to ensure their practice matched their theoretical assessment. The training records showed that most staff had received up to date training in the mandatory subjects. There was also a number of in-house sessions planned to cover any shortfalls. As required following our last inspection the manager had received appropriate training to enable him to work with residents. Staff received training in topics relating to mental health needs and other subjects relevant to the residents, Care Homes for Adults (18-65 years) Page 27 of 35 Evidence: such as diabetes. All staff who completed surveys indicated that they had relevant training that helped them to understand the needs of the residents and kept them up to date. One commented, Training is always available by professionals. Another member of staff told us, We have plenty of training and support. Over half of the care staff held a National Vocational Qualification (NVQ) level 2 in health and social care. Staff who completed surveys confirmed that they had regular supervision sessions. Care Homes for Adults (18-65 years) Page 28 of 35 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were clear management and administration systems and there was a good level of consultation, which meant that people using the service were able to contribute to service development. Evidence: The registered provider also manages the home on a day to day basis. He is supported in the management role by the lead nurse and the administrator. The AQAA told us The skills and qualifications of these three individuals span the clinical, financial and operational aspects of running the home, ensuring it runs smoothly. Each member of the management team had a clear remit and staff and residents we spoke to were aware of who they needed to go to in different situations. For example, the lead nurse told us that he was responsible for the clinical decisions and the registered manager made decisions regarding staff. The lead nurse did not have any supernumerary time and told us that he kept care plans up to date when there were quiet moments. There were some systems in place for monitoring the quality of the service but these needed to be further developed in order to ensure a regular cycle of audit, planning Care Homes for Adults (18-65 years) Page 29 of 35 Evidence: and development. The AQAA told us that this was one of the plans for the next year. The manager discussed that they had started working with a quality assessment tool but it had not been completed at the time of our visit. Annual questionnaires were sent out to residents, families and visiting professionals. The last survey, conducted in November 2009, had all positive responses. Residents also had opportunities to make their views known during weekly resident meetings. The AQAA told us, ...Residents at Elsenham House have the chance to express their views, wishes and ideas and the manager always listens to their suggestions no matter how small they are. The fire procedure was on display in each of the houses. Staff had received fire safety training and staff and residents we asked were aware of what to do in the event of a fire. Fire safety equipment and appliances were serviced. The AQAA told us that maintenance and servicing of other equipment and installations was up to date and we saw a random sample of certificates to confirm this. Care Homes for Adults (18-65 years) Page 30 of 35 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 20 13 Medicines must be 01/04/2009 administered to people living in the home in line with prescribed instructions and reords kept. This is a repeated requirement. This will ensure all medicines can be accounted for in full. Care Homes for Adults (18-65 years) Page 31 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 15 Care plans must include 30/04/2010 sufficient information about how to support people who are subject to restrictions under the Mental Health Act. Copies of the relevant papers should be kept on file. This is to ensure that staff protect peoples rights 2 9 13 There must be clear risk assessments and management plans to support people to take risks as part of an independent lifestyle. This would include risks associated with going out unescorted. This is to protect the health and safety of people living in the home. 30/04/2010 3 19 15 Care plans to support people 30/04/2010 with health care needs, must be followed. Care Homes for Adults (18-65 years) Page 32 of 35 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure that peoples health care needs are met. 4 19 15 Care plans must provide 30/06/2010 staff with sufficient detail about how to support people to meet their personal and health care needs in a consistent way. This is to promote people health and welfare. 5 20 13 Medicines must be 30/04/2010 administered to people living at the home in line with prescribed instructions. This must be demonstrated by the homes record-keeping practices ensuring all medicines are administered safely and can be accounted for in full. This will ensure all medicines can be accounted for in full. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 6 20 Residents who have staff support to manage their money should have clear care plans, which they have agreed to. It is recommended that care plans relating to the use of medicines prescribed for administration at the discretion of Page 33 of 35 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations nursing staff are promptly updated to reflect changes to prescribed doses and copies of such care plans are kept alongside medication charts for easy reference. 3 20 It is recommended that medicine audits are conducted more frequently to promptly identify issues and discrepancies arising and enable medicines to be accounted for in full. It is recommended that the new coding system relating to newly implemented medication charts is adopted. The services own procedure for safeguarding vulnerable adults should be reviewd to ensure it contains up to date information and clear guidance about how and where to report any suspected or alleged abuse or harm. The use of door guards with sound sensors should be extended to all areas of the home. The procedure for prevention and control of infection should be reviewed to ensure it contains information specific to Elsenham House Staffing levels should be kept under review to ensure there are enough staff at all times of the day and night to support residents to meet their health, personal and social care needs. Systems for monitoring and improving the quality of the service should be further developed to ensure that areas in need of improvement are identified and acted upon. 4 5 20 23 6 7 24 30 8 33 9 39 Care Homes for Adults (18-65 years) Page 34 of 35 Helpline: 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. 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. 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