CARE HOME ADULTS 18-65
34 Elsee Road 34 Elsee Road Rugby Warwickshire CV21 3BA Lead Inspector
Justine Poulton Unannounced Inspection 17th November 2005 09:30 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 34 Elsee Road Address 34 Elsee Road Rugby Warwickshire CV21 3BA 01788 547781 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) RMH Homes Mrs Angela Courtney Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st July 2005 Brief Description of the Service: Elsee Road is a large terraced Victorian house providing a permanent home for four people with learning disabilities and respite stays for one person. The home is near the centre of town. There is no parking at the home, and the road has double yellow lines, and residents permit parking only. Care staff support residents at all times when they are at home. Residents are not routinely at the home during the day, though some residents will arrange to be at home occasionally. The house is one of four services operated by Rugby Mencap Hostels that provides residential care for people in Rugby. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over two week days from 10:30 to 12:30 and 14:00 to 16:00. The residents, staff and manager co – operated fully with the inspection. A total of 19 standards were inspected on this occasion, of which four had shortfalls. The majority of the requirements from the previous inspection were met. All of the residents were at home for part of the inspection, and were spoken with informally. Staff members on duty at various times during the inspection were also spoken with informally. The manager was available throughout the inspection. In addition to this records, files and policies and procedures were also inspected. The inspector would like to thank the residents, manager and staff for their cooperation and hospitality during the inspection. What the service does well: What has improved since the last inspection?
Since the last inspection of this home which was undertaken on 1 July 2005, considerable work has been undertaken to meet the requirements made. Full assessments for respite clients are in place, clear and consistent care planning documentation for permanent residents assists staff with meeting individual needs, as does up to date risk assessment. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 6 Residents have agreed their care plans, thus demonstrating that they have been involved in their compilation. Records of staff training demonstrates that the organisation has a commitment to ensuring that competent and skilled staff support the residents, as do the records of staff supervision. The health and safety of residents, staff and visitors is maintained. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 There is a clear assessment and care planning system in place to adequately provide staff with the information they need to satisfactorily meet resident’s needs. The inclusion of which bedroom is occupied by the residents in their contracts would further safeguard their placement in the home. EVIDENCE: Key standard 2 was not inspected at the last inspection of this home which took place on 1 July 2005. A requirement carried forward from a previous inspection was for full assessments to be completed for all residents visiting the home for respite stays. The files of two respite clients were looked. Both contained completed social services assessment of needs documentation, therefore this standard is deemed to be met. Key standard 5 was inspected at the last inspection of this home which took place on 7 July 2005. A requirement was made for the addition of bedrooms occupied by residents to be incorporated in their contracts. The residents contracts have yet to be updated as work to produce them in a more user friendly format has been undertaken. This requirement is therefore carried forward. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 There is a clear, consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents needs. The people living in this home are supported to take responsible risks based on effective risk management strategies that are agreed and recorded on the individuals care plan. EVIDENCE: Key standards 6 and 9 were inspected at the last inspection of this home which took place on 1 July 2005. Requirements were made for up to date and accurate care plans to be maintained for all residents, and for risk assessments to be reviewed, expanded on, dated, signed and future review dates incorporated Evidence was available at this inspection to confirm that all permanent residents care plans had been reviewed with future review dates set for 6 months time. Evidence was also available to confirm that residents risk assessments had been reviewed and updated as required. These standards are therefore deemed to be met. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,15, 16 and 17 People living in this home have opportunity to live ordinary and meaningful lives within the local community in which they live. Support to maintain and develop family links and friendships is available if requested. EVIDENCE: Key standard 12 was inspected at the last inspection of this home which took place on 1 July 2005. A requirement was made for consideration to be given about how best to support residents if they choose not to attend their day service placement. It was advised by the manager that negotiations have been taking place to obtain additional funding for one resident in order to provide more flexibility and increase choice on day time activities. The manager also stated that another resident is currently making additional payments to the organisation from his own money in order to increase the level of support available to him for day care. Each resident has a weekly programme of activities based on their interests and hobbies, which makes use of local college courses and a local day service. Courses such as numeracy, literacy, cookery and art are undertaken, along with work placements such as in a coffee shop and on a farm.
34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 11 Each resident has a personal diary in which any activities they undertake are recorded. Any contact with their families and friends are also recorded in this diary. Residents are encouraged to maintain contact with their families if they wish. Friendships are also encouraged. Support to visit friends and relatives is provided where requested. The home aims to be domestic in nature. As such any routines in place are in keeping with this and are implemented by the residents. Getting up and going to bed times are determined on an individual basis, as is the choice of meals eaten. Each resident has domestic tasks which they complete on a daily basis to ensure the smooth running of the home for all concerned. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20 Resident’s health-care needs are identified on their care plan and being met with appropriate specialist support. EVIDENCE: Key standards 18, 19 and 20 were inspected at the last inspection of this home which took place on 1 July 2005. Requirements were made at this time for evidence to be available to confirm that residents have agreed their care plans and for evidence to be available to confirm that all residents are offered routine healthcare appointments at the recommended intervals. Inspection of a sample of residents care plans at this inspection confirmed that they are now signing their care plans to confirm their agreement with the contents. Records were also available to confirm that routine healthcare appointments have been offered to all residents. These standards are therefore now deemed to be met. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Knowledge and understanding of adult protection issues and the effective policies and procedures in place in the home for the protection of vulnerable adults provides a safe environment. EVIDENCE: Each resident has been given a copy of the organisations policy and procedure on abuse. This uses pictures as well as text and talks about peoples rights, what abuse is, who can abuse, how abuse can be stopped and what the organisation will do. Certificates were available to confirm that all of the staff have received training in the prevention of abuse. The manager demonstrated a clear understanding of abuse and how to deal with it should it ever be alleged. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home is clean and hygienic with policies in place to ensure that the risk of infection is minimal. EVIDENCE: An organisational infection control policy is in place in the home. Staff are required to sign a document when they have read the policy to confirm that they understand its contents. This is a relatively new policy. Two staff had signed to say that they had read and understood it on the day of the inspection. A procedure for the prevention of infection and cross contamination was also in place. This includes details on how to transport laundry through the kitchen to the washing machine in the utility area safely. It was noted during the inspection that personal protective clothing is provided for use by all staff. On the day of the inspection the home was clean and tidy with no offensive odours apparent. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users benefit from a well-trained, supervised and enthusiastic staff team who work towards common goals. EVIDENCE: Key standards 32 and 35 were not inspected at the last inspection of this home which took place on 1 July 2005. A requirement carried forward from a previous inspection was for records of staff training that can evidence the competence and skills of staff, and the organisations training plan to be maintained. A training plan for 2005 was available during this inspection. A training file was also in place which contained records of all training undertaken by each member of staff. These standards are therefore now deemed to be met. Key standard 36 was inspected at the last inspection of this home which took place on 1 July 2005. A requirement was made at this time for staff to receive formal recorded supervision a minimum of six times per year. Evidence was seen during this inspection to confirm that this has been actioned. This standard is therefore now deemed to be met. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 and 43 The lack of a quality monitoring system limits the ability of the service to ensure that the views of residents and significant others are fully taken into account. Records are stored safely and securely. Health and safety is managed safely within the home. The lack of financial and business planning places the Residents in a vulnerable position. EVIDENCE: Key standards 39, 42 and 43 were not inspected at the last inspection of this home which took place on 1 July 2005. Requirements carried forward from a previous inspection were for regular reviews of the quality of the service based on its Statement of Purpose, aims and objectives and resident consultation to take place, for a certificate of gas boiler safety to be sent to the commission and for copies of the 2005/06 business plan for 34 Elsee Road along with projected income and expenditure for 2005/6 and the audited accounts for 2003/04 also to be forwarded. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 17 At this inspection the manager stated that no formal quality monitoring process had been implemented as yet, therefore this requirement remains outstanding. A gas boiler safety certificate was forwarded to the commission, therefore this requirement has been met. The commission is still awaiting the requested information regarding the business plan and expenditure, therefore this requirement remains outstanding. At the last inspection requirements were made for door wedges to be removed from fire doors, and an approved system of holding these doors open to be installed. This had been actioned at this inspection. A requirement for the homes fire risk assessment to be available was also made. This document was in place at this inspection. Resident and staff records were observed to be stored safely and securely, in good order within locked cabinets in the homes office / quiet lounge. 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x 2 Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 3 x Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
34 Elsee Road Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x 1 x x 2 1 DS0000004287.V267324.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5 Requirement Timescale for action 31/08/05 2 YA39 24 3 YA43 25 The addition of bedrooms occupied by residents is required in their contracts. (Not met at this inspection) The registered person must 30/09/05 make regular reviews of the quality of the service based on its Statement of Purpose, aims and objectives, and based on resident consultation. (Not met at this inspection) The registered person must 08/08/05 ensure that copies of the business plan for Elsee Road 2005/6, the audited accounts for Elsee Road for 2003/4 and projected income and expenditure for Elsee Road for 2005/6 are submitted to the Commission. (Not met at this inspection) 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 20 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 - 34 Elsee Road DS0000004287.V267324.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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