CARE HOME ADULTS 18-65
Baba Sawan Lodge 11 Bodnant Avenue Evington Leicester LE5 5RB Lead Inspector
Kim Cowley Unannounced 25 August 2005 10:00
th 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 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 Stationary 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 C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Baba Sawan Lodge Address 11 Bodnant Avenue Evington Leicester LE5 5RB 0116 2730008 None None Baba Sawan Lodge Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Acting Manager Care home 10 Category(ies) of LD Learning disability(10) registration, with number of places Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 19.10.04 Brief Description of the Service: Baba Sawan Lodge opened in 1989 as a home for younger adults with learing disabilities. The premises are detached and situated in a residential area of Evington. A good range of local amenities are within walking sistance 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 fllor. At the rear of the home is a large garden with a patio, lawn, and seating areas. Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on a weekday. The inspector met all four residents, the Acting Manager, and the Owner. The premises were toured and one resident allowed the inspector to see his bedroom. Care, medication, and other records were inspected. What the service does well: What has improved since the last inspection?
The Statement of Purpose has been amended to include information about the numbers and sizes of communal and individual rooms.
Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 6 The dining room has been redecorated and has a new non-slip floor. The blinds in the lounge have been repaired and the pendant light fitted with a new lampshade. 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. Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 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 standard(s) 1, 2 The Statement of Purpose has been amended and now meets requirements. All prospective residents are fully assessed prior to admission to ensure their needs can be met. EVIDENCE: Since the last inspection the Statement of Purpose has been amended to include information about the numbers and sizes of communal and individual rooms. The Acting Manager meets and assesses all prospective residents. She said ‘We have to make sure they are right for the home and the home is right for them.’ Following this, prospective residents make a series of short visits to the home either on their own or with their family. During this time staff get to know them and a written assessment of their needs is carried out. The Acting Manager and the Owner then meet to make a decision about whether or not to offer a place. At present the home does not take residents with challenging behaviour. Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 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 standard(s) 6, 7, 8 Care plans are of good quality, being comprehensive and subject to regular review and evaluation. Residents are consulted on all aspects of their care and encouraged to make choices about their lifestyles. Opportunities are available for residents to contribute to the day-to-day running of the home. EVIDENCE: All residents have comprehensive care plans, which are evaluated and updated as necessary. Three were inspected in detail and contained extensive information to help staff meet residents’ needs. One resident is involved in the writing of his own care plan and is consulted when changes are made. Residents are encouraged to determine their own lifestyles. For example: • • Bed/getting up times are flexible. For example, one resident goes to bed early (at 9pm) and get up at 5am. Others stay up until 11pm and have a lie in at weekends. Some residents choose their own clothes in the morning from their wardrobes, other choose between two or three outfits that staff have laid out for them.
C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 10 Baba Sawan Lodge • • All resident help themselves to cold drinks, and some to hot drinks with staff supervision. Two residents smoke and do this in the garden. A residents’ meeting is held every two months. Staff attend to take minutes and encourage residents to share their views. Key workers also assist residents in having a say in the running of the home. Some residents communicate with staff in Makaton. Residents are able to take responsible risks and written risk assessments are kept with their care plans. Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 11 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 standard(s) 11, 12, 13, 14, 15, 16, 17 Good opportunities are available for residents to take part in activities, education and training. Spiritual and cultural needs are met in the home or in the local community. A varied, wholesome and multicultural diet is provided. EVIDENCE: The home provides a variety of leisure activities for residents including: • • • • Arts and crafts Day trips out Annual holidays Discos, pubs, restaurants Some residents attend a local neighbourhood centre Asian group. Languages spoke in the home include Gujarati, English and Urdu, although all residents and staff can communicate in English. Residents have differing spiritual needs and these are met in the home and at local temples, churches, and mosques.
Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 12 The home is situated in a multicultural area with good local facilities for all faiths and cultures. Some residents attend day centres, other stay in the home or are out and about in the local community. Others go to college for both educational and leisure course and activities. The home has a ‘family’ kitchen which residents use too, either under supervision or subject to a satisfactory risk assessment. In the week breakfast is at 8am, a light lunch is at 12 noon (or residents take a packed lunch if they are going out), and tea, the main meal, at 5pm. At weekends a cooked breakfast is served at 9am, a cooked lunch at 12 noon, and a light tea at 5pm. On the day of inspection the Acting Manager was seen asking residents what they wanted for lunch, and providing a variety of dishes depending on their choices. Care staff do the cooking and the menu is varied, wholesome, and multicultural. An Asian (including halal and vegetarian) and English diet is catered for. The Acting Manager said ‘We know their (the residents’) likes and dislikes and if we give them something they don’t like they soon let us know!’ On a resident’s birthday they choose their favourite restaurant and all residents are taken there for a meal. Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 13 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 standard(s) 18, 19, 20 Staff treat residents with respect and dignity. Health needs are met by a range of local professionals. Medication is properly kept and administered. EVIDENCE: The Acting Manager said staff are trained to treat residents with dignity and respect and to take account of their wishes at all times when delivering personal care. Each resident’s personal care needs are set out in their care plans. Staff liaise with day centre and college staff, where appropriate, to ensure consistently in the way needs are met. Residents use heath services in the local community as far as possible, although some need specialist services. Doctors, dentists, opticians, etc, are all within walking distance of the home. District Nurses visit as necessary. A private chiropodist comes to the home every 8 weeks. Medication is kept securely and the ‘Nomad’ system is used. The contract pharmacist inspected on 15.02.05 when no recommendations or requirements were made. Staff are trained in house to administer medication, and also undertake a three months ‘Safe Handling of Medication’ course. At present only five residents are on medication.
Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 14 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 standard(s) 22 The complaints procedure is in need of amending. EVIDENCE: The home’s complaints procedure is displayed in the entrance hall and is also in the Statement of Purpose/Service Users’ Guide. The Acting Manager said residents are also told verbally about what to do if they’re unhappy about anything. The complaints procedure must be amended to state that complaints can be made to CSCI at any time, complainants do not have to go through staff at the home first. Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 15 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 standard(s) 24, 30 The premises are comfortable, well maintained and clean. EVIDENCE: The home has a large comfortable lounge with two seating areas, a TV, video and sound system. French windows lead from the lounge to the patio and garden. The dining room has been redecorated and a new floor laid. There are two dining tables, one for four residents and one for six. There is one bedroom on the ground floor, five on the first floor (including one double), and two on the top floor (including one double). There are shower rooms on the ground and first floors, and a bathroom on the top floor. Communal areas and the resident’s bedroom inspected were homely and personalised. The Owner oversees the maintenance and redecoration of the home. A maintenance book is kept. This was inspected and showed that jobs are recorded by staff and signed off by the Owner when completed
Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 16 All areas inspected were clean, tidy and fresh. Care staff do the cleaning following a rota, and a contractor comes in to shampoo the carpets. The Acting Manager said ‘I’m proud of this home. When visitors come they tell me how clean it is’ Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These Standards will be inspected at the next inspection. Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These Standards will be inspected at the next inspection. Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 19 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 3 3 x x x Standard No 22 23
ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Baba Sawan Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 20 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 16 Good Practice Recommendations Baba Sawan Lodge C51 C01 S6336 Baba Sawan Lodge V245286 250805 Stage 2.doc Version 1.40 Page 21 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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