Inspection on 19/12/05 for Baba Sawan Lodge

This inspection was carried out on 19th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Baba Sawan Lodge 14/05/07

Baba Sawan Lodge 29/06/06

Baba Sawan Lodge 25/08/05

Baba Sawan Lodge 19/10/04

Baba Sawan Lodge 07/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Baba Sawan Lodge 11 Bodnant Avenue Evington Leicester Leicestershire LE5 5RB Lead Inspector Linda Clarke Unannounced Inspection 19th December 2005 11:00 Baba Sawan Lodge DS0000006336.V271382.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 Baba Sawan Lodge DS0000006336.V271382.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. Baba Sawan Lodge DS0000006336.V271382.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Baba Sawan Lodge Address 11 Bodnant Avenue Evington Leicester Leicestershire LE5 5RB 0116 2730008 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) Baba Sawan Lodge Limited Mrs Peggy Lorraine Baxter Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Baba Sawan Lodge DS0000006336.V271382.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 25th August 2005 Brief Description of the Service: Baba Sawan Lodge opened in 1989 as a home for younger adults with learning disabilities. The premises are detached and situated in a residential area of Evington. A good range of local amenities are within walking distance of the home. There is a regular bus service into the City Centre, which is a ten-minute ride away. Baba Sawan Lodge has bedroom and bathroom facilities located on the ground, first, and second floors. There is a large lounge and a dining room on the ground floor. At the rear of the home is a large garden with a patio, lawn, and seating areas. Baba Sawan Lodge DS0000006336.V271382.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection that took place between 11.00am and 1.30pm. When undertaking Inspections, the Commission for Social Care Inspection focuses on the outcomes of individuals staying in the home. To support this, two residents were ‘case tracked’. This means that the care records and care plans of residents were checked. The Responsible Individual and Manager contributed to the Inspection. Opportunity was also taken to look around parts of the home. What the service does well: What has improved since the last inspection? What they could do better: The exterior to the front of the property being tidied would improve the appearance of the home. Residents would benefit if the lounge were to be refurbished, including fabric and furnishings. The leadership of the home to be formalised by the Manager submitting an application to the Commission for Social care Inspection to become the Registered Manager. Baba Sawan Lodge DS0000006336.V271382.R01.S.doc Version 5.0 Page 6 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. Baba Sawan Lodge DS0000006336.V271382.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 Baba Sawan Lodge DS0000006336.V271382.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): EVIDENCE: Standards within this section were not inspected on this occasion. Baba Sawan Lodge DS0000006336.V271382.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, 8 and 9. Residents are consulted on all aspects of their care and encouraged to make choices about their lifestyles, care plans detail as to how care needs are to be met. EVIDENCE: Residents whose records were viewed had comprehensive care plans, which are regularly reviewed and updated. Care plans focus on all aspects of care, which includes personal care, social and recreational pursuits and goals to attain and maintain maximum independence. Individual cultural needs are detailed within care plans; a mutli cultural staff group meets resident needs by focusing on religion, diet and spoken language. Risk assessments are in place, with particular reference to those individuals who are supported in maintaining an independent lifestyle. On the day of the Inspection one gentleman went out independently, which is managed within a risk assessment framework. A residents’ meeting is held every two months. Staff attend to take minutes and encourage residents to share their views. Baba Sawan Lodge DS0000006336.V271382.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, 14 and 17. Residents access a wide range of community resources, including spiritual and cultural events. A varied, wholesome and multicultural diet is provided. EVIDENCE: Individuals access a variety of day care occupations, which includes day centres and colleges, providing residents with the opportunity to interact with the local community and to study. The spiritual needs of service users are met within the home and support is offered to service users accessing places of worship. Muslim service users access the local Mosque whilst the Hindu service users visit the local Temple. The cultural needs of individuals are supported by a staff group, which reflect the population of Baba Sawan. A local neighbourhood centre holds an Asian Group meeting weekly, to which some residents attend, other local resources include public houses, restaurants, discos and shops. A holiday at Sherwood Forest, Centre Parcs was enjoyed by a group of residents earlier in the year. Baba Sawan Lodge DS0000006336.V271382.R01.S.doc Version 5.0 Page 11 The home provides service users with a balanced and nutritious diet, which reflects the needs of individual service users; menus are in place to reflect the cultural diversity of residents within the home, which include vegetarian, traditional English fayre and Halal prepared food. Baba Sawan Lodge DS0000006336.V271382.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): EVIDENCE: Standards within this section were not inspected on this occasion. Baba Sawan Lodge DS0000006336.V271382.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): EVIDENCE: Standards within this section were not inspected on this occasion. The Registered Person confirmed that the Complaints Procedure has been revised, and now states that complaints can be referred to the Commission for Social Care Inspection and need not necessarily be made to the home. Baba Sawan Lodge DS0000006336.V271382.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): 24 Communal areas are basic in appearance and would benefit from refurbishment and decoration. EVIDENCE: The home has a large lounge, which provides ample seating for all. Residents would benefit from new chairs being provided, as the current furniture appears worn. The Registered Person did state that new sofas and chairs were to be purchased next year. The décor of the lounge looks ‘tired’ and the carpet is stained and bleached by the sun. The decoration of the lounge and replacement of carpets would provide residents with a more homely environment in which to relax. The lounge incorporates a television, video and music system, for the benefit of residents; television channels include those specific to the Asian culture. The Registered Person has replaced the windows and exterior doors, and is planning to decorate some bedrooms following remedial work. The ‘dumping’ of ironing boards, boxes and other waste in the front garden detracted the appearance to the front of the house. The Manager stated this was to be cleared. Baba Sawan Lodge DS0000006336.V271382.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): 32, 33 and 35. A competent staff group, are able to provide culturally appropriate care and support. EVIDENCE: Baba Sawan currently employs seven members of care staff, one staff member has attained a level 2 National Vocational Qualification in Care, with two members of staff working towards the award. In addition one member of staff has attained the level 2 Learning Disability Award Framework training. The staff group reflect the cultural diversity of individuals residing at the home, and are able to offer appropriate communication (language), cultural and spiritual support, within a supportive environment. Staff are to access training in Dementia, to enable them to offer appropriate support. Baba Sawan Lodge DS0000006336.V271382.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): 37, 39 and 42. Appropriate management systems are in place to ensure the health and safety of residents. EVIDENCE: The Manager of the home has been in post for three years, to date the fitness of the Manager has not been confirmed by the Commission for Social Care Inspection, as an application to become the Registered Manager has not been submitted. The Manager did state that she would be submitting an application to the Commission for Social Care Inspection for consideration. The Manager has enrolled on a course to undertake the Registered Managers Award and level 4 National Vocational Qualification in Care. As part of Quality Assurance questionnaires have been devised which are circulated to relatives and visiting professionals, at the time of the Inspection no questionnaires had been returned. Records relating to aspects to health and safety, fire, electrical and gas systems were viewed and found to be in good order. Baba Sawan Lodge DS0000006336.V271382.R01.S.doc Version 5.0 Page 17 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 X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Baba Sawan Lodge Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000006336.V271382.R01.S.doc Version 5.0 Page 18 No 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 YA35 Regulation 18(1) Requirement The Registered Person to ensure that all staff access training in Dementia Care. Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations It is strongly recommended that the lounge is refurbished to include the provision of new sofas and chairs, decoration and new carpets. Baba Sawan Lodge DS0000006336.V271382.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Baba Sawan Lodge DS0000006336.V271382.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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