Latest Inspection
This is the latest available inspection report for this service, carried out on 23rd February 2010. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
For extracts, read the latest CQC inspection for The Elms.
Annual service review
Name of Service: The Elms The quality rating for this care home is: The rating was made on: two star good service 2 4 0 3 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Debby Ames Date of this annual service review: 2 2 0 1 2 0 1 0 Annual Service Review Page 1 of 7 Information about the service
Address of service: 34 Elmgrove Road Gorleston Great Yarmouth Norfolk NR31 7PP 01493657069 Telephone number: Fax number: Email address: Provider web address:
irenebeck@btconnect.com Name of registered provider(s): Conditions of registration: Category(ies) : old age, not falling within any other category Conditions of registration: The Elms Residential Care Home Ltd Number of places (if applicable): Under 65 Over 65 0 21 The registered person may provide the following categories of service: Care Home - PC to service users of the following gender: Both whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - code OP Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service The Elms is a converted property registered as a care home to look after 21 older people. It is situated in quiet street in Gorleston near Great Yarmouth. The premises are over two storeys with access to the first floor by a shaft lift. The accommodation consists of 18 single occupancy bedrooms as double rooms have now been changed to singles. The home has an enclosed garden surrounding the building, with a small area at the front for parking.
Annual Service Review Page 2 of 7 2 4 0 3 2 0 0 9 The fees in the home vary according to peoples individual support requirements and do not include hairdressing, chiropody, newspapers or personal toiletries. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: (1) The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. (2) Information we have about how the service has managed any complaints. (3) What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. (4) The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. (5) Relevant information from other organisations. (6) What other people have told us about the service. What has this told us about the service? We received the Annual Quality Assurance Assessment (AQAA) before this service review, which gave us good information about how The Elms has continued to improve since the last key inspection. Completed questionnaires were returned to the Commission by two residents/relatives and three members of staff. All three staff members confirmed in their responses that they know what to do if someone has any concerns but both residents responded no to the questions Do you know how to make a formal complaint? and Is there someone you can speak to informally if you are not happy? Some of the additional comments made by the residents to the question: What does the home do well? included: ...the staff are very kind... and ...the room and my bed are always clean and changed regularly... Additional comments made about what the home could do better were: ...answering the bell when wanting to use the commode plus a quicker response... and ...employ more staff... Other additional comments included: ...need more staff on during the afternoons/evenings... ...sometimes because of staff shortages staff fly in and out of the rooms without saying who they are. Verbal communication is vital for people who are visually impaired... and ...visiting nurses are caring but also rushed. Each nurse Annual Service Review Page 4 of 7 could perhaps tell residents, who are capable of understanding, how they are doing... The staff comments in what the home does well included: ...its a homely home and very clean and friendly... ...all members of staff work as a team and all the residents are very happy with the care they receive... ...the care and care planning is good. The quality of food is good. The home is clean and well equipped. The staff are smart and punctual. The staff are caring and supporting of one another... The staff responses to what the home could do better included: ...the decor could be updated... ...more activities... ...having more aids to transfer people with... ...if the manager was to interact more with the residents, they would feel better able to approach her if they have a problem... Meanwhile, the information provided in the AQAA has told us the following: The Statement of Purpose/Service Users Guide is regularly reviewed and updated as necessary. A maintenance person has been employed on a permanent basis, so any aspects of the property that require attention are dealt with promptly and efficiently. Decorating and refurbishment programs have improved substantially during the last 12 months. A planning application has been submitted and, once permission is granted, the property will be extended and the current facilities improved. The main bathroom has been refurbished and fitted with a fully compliant disabled suite. Residents and families are being offered more choices in respect of end of life care and training in this area is being looked into. A specific member of staff is now responsible for infection control within the home and another staff member has taken on the role of falls co-ordinator. Last years AQAA stated that Hydration was an issue that the staff and management at The Elms planned to address and this has been confirmed as having been achieved to an acceptable level. Activities are still ongoing and external trips/outings now form part of the activities offered. A number of mandatory training courses are now incorporated into the induction programme for new staff.
Annual Service Review Page 5 of 7 Formal one-to-one supervisions with staff are now being carried out every eight weeks. A Policy Operating Manual has been completed, which has enabled the manager to have a reference point for every eventuality. It is planned that the results and outcomes of service user surveys will be made available to current users of the service. It was also noted from the AQAA that all policies and procedures were last updated/reviewed in December 2008. It was confirmed that no formal complaints or safeguarding referrals have been received since the last inspection and the Commissions opinion, following this Annual Service Review, is that The Elms continues to provide good outcomes for the people living there. What are we going to do as a result of this annual service review? There will be no changes to our inspection schedule following this review and a key inspection will be carried out by 23rd March 2012. However, the service can be inspected at any time if the Commission have any concerns about the quality of the service or safety of the people using the service. Annual Service Review Page 6 of 7 Reader Information
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