Inspection on 14/11/06 for Ebor Lodge

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ebor Lodge 28/01/09

Ebor Lodge 24/11/05

Ebor Lodge 05/07/05

Ebor Lodge 02/11/04

Ebor Lodge 27/07/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Ebor Lodge 92 Westbourne Avenue Hull East Yorkshire HU5 3HS Lead Inspector George Skinn Key Unannounced Inspection 14th November 2006 09:30 Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 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 Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 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. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ebor Lodge Address 92 Westbourne Avenue Hull East Yorkshire HU5 3HS 01482 342099 01482 342099 cazebor@aol.com 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) Mrs Rosina Clarke Mrs Carol Mason Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 Brief Description of the Service: Ebor Lodge is a large corner house situated in a service userial area in the west of the city of Kingston Upon Hull. The house has three floors on which service users bedrooms are located. There are sufficient bathrooms and toilets available as well as two lounges, one designated for smoking, and a dining room. A patio area to the rear of the house is available for service users. The home has a laundry and a kitchen and these services are provided. There are car park facilities for two cars. The home is close to shopping amenities in the local area and has access to bus routes to the rest of the city. Ebor Lodge is registered to provide personal care and accommodation for a maximum of thirteen service users. The registration category allows the home to care for service users with a mental disorder, excluding learning disability or dementia. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced site visit undertaken to the home and lasted for 6 hours. During the site visit the service users were interviewed, the environment was looked at, as were some of the records. Prior to the site visit surveys were sent to service users, staff; their opinions were used to form judgement. What the service does well: What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 6 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 Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 7 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed prior to moving into the home. EVIDENCE: Evidence in the service users files indicated that their needs are assessed prior to moving into the home. There was a copy of the care management assessment along with the homes own assessment held on file. Evidence was seen of service users signing their own individual care programmes. Prospective service users are invited to the home to spend a day and have their meals with other service users. The home liaises closely with the service users care Co-ordinators prior to admission. Newly admitted service users confirmed that they had been involved in the admission process and were very satisfied with the admission procedure. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users changing needs are well managed. Taking risks is seen as part of the service users’ choice in how they wish to live their lives. EVIDENCE: All service users have individual plan of care; these cover all aspects of personal and social support and healthcare needs. Any restriction of freedom of choice is included in the care plans; evidence was seen of full involvement of all those who have an input into the service users care being involved with this process, along with the service users. Service users care plans are reviewed every six months and are signed by the service users. Discussion with the service users indicated that they were aware of their care pans and were fully involved with any reviews. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 9 The service user care plans include a comprehensive risk assessment, these are complied with input from the service users and they are able to negotiate around the level of acceptable risk, and how this may impact on their freedom of movement; these are regularly reviewed again with input from all concerned. One service user has been restricted to where she can smoke and she fully understood the reasons why and the risks involved. Service users are enabled to make decisions about their daily living patterns, and they are encouraged to maintain their independence; both service users and staff view this positively. Many of the service users handle their own finances, with the home being agents for collection of relevant benefits only. It was found that some information is now out of date and needs reviewing. Some of the service users are now over 65 years of age therefore the registration of the home needs to reflect this. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users take part in age appropriate activities with peers Service users are part of the local community 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 well balanced diet EVIDENCE: Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 11 Service users are provided with information about activities outside of the home, this is provided either verbally or by use of posters and leaflets. Information relating to public transport and church services is posted in the home for service users to view. Service users are assisted to exercise their political rights and are encouraged to register and cast their votes. Service users visit friends and relatives on a regular basis. Service user commented on being able to go out as they pleased and visit friends and relatives on a regular basis. There are set meal times but service user can choose whether to eat or not at these times; food is made available or kept for them if they choose to eat at a different time. The home offers a choice of meals with likes and dislikes responded to; menus seen were varied and compiled with healthy eating in mind. Whilst there are no service users in employment attempt are made to motivate and encourage attendance at the local college for recreational courses. Some service users’ take up these options and details are held in their diary notes. The home encourages service users to maintain links with friends and family, however limited this may be. The general routine and structure of the day was observed with staff interacting well with service users, and conversation flowed freely. Keys would be available for service users’ bedroom doors if requested and risk assessment would be made if appropriate. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users receive personal care in the way they prefer Service users physical and emotional health needs are met Service users could retain and administer their own medication where appropriate. Service users are protected by the homes procedures for handling medication. EVIDENCE: Written evidence indicated that personal preferences are considered and respected when formulating care plans; this also indicated that the home cares well for service users’ health care needs. Staff recognise when service users have a health problem and support them to maintain their healthcare needs. Everyone is registered with a General Practitioner (GP) of their choosing, and receives appropriate health checks by dentists, opticians, audiologists, chiropodists, therapists and Community Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 13 Psychiatric Nurses (CPNs). Visits to service users from medical and healthcare practitioners take place in private in service users’ rooms. The home uses the Nomad monitored dosage system for receipting, storing and administering medication. Policies for staff handling medication and for service users to self-medicate are available and are known by the staff. Facilities are provided for service users wishing to self-medicate, to lock away their medication. There are no controlled drugs held in the home at the moment, but systems in place and facilities for storage are satisfactory, should there be. Proper procedures are in place for the handling of medication following the death of a service user. Records for receipting, storing, administering and returning medication are satisfactorily maintained. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users feel their views are listened to and acted upon. Service users are protected from abuse, neglect and self harm. EVIDENCE: Service user said they knew who to complain to if they had any concerns and were confident that these would be taken seriously. When asked none of the service users had any concerns or complaints. The home has a written complaint procedure, which has a timescale of 24 hours to acknowledge any complaint made; the Commission for Social Care Inspection (CSCI) address and telephone number are included in this. The home has a copy of the East Riding of Yorkshire Vulnerable Adult Guidance manual and a whistle blowing policy. The home has produced a procedure to include guidance for staff to ensure the protection of the service users in their care. The manager has attended the vulnerable adult training and this is being disseminated amongst the staff. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment. The home is clean and hygienic EVIDENCE: The home is suitable for the needs of the present service users and is generally well maintained. The main lounge is used by those service users who smoke and as a consequence is in constant need of redecoration; an extractor fan is in place and does alleviate some of the smoke. There is a non-smoking lounge available for those who do not smoke. The service users’ rooms were generally well maintained and decorated with service users taking a pride in their own surroundings. One-service user spends the majority of the day in bed but the home has provided the appropriate equipment and a room which is suitable for their needs. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. Service users are supported and protected by the homes recruitment policies. Service users’ individual and joint needs are met by appropriately trained staff. EVIDENCE: Staff file inspected contained the information required; Criminal records Bureau (CRB) checks have been obtained prior to staff starting work, and appropriate references have been sought. Evidence was provided which would indicate that there is staff training and development which meets the Sector Skills Work Force training targets and ensures staff fulfil the aims of the home. The staff continue to receive training concerning the needs of the service users. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 17 Examination of records and interviews with staff indicated a high level of specific training and a level of qualification above the 50 recommended minimum. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 &42 Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Service users are confident their views underpin all self-monitoring review and development by the home. The health safety and welfare of the service users are promoted and protected. EVIDENCE: The home have obtained both part A and B of the Local Authorities Quality Assurance scheme and observation during the inspection indicated that the service users views are actively sought on the functioning of the home. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 19 Staff receive training in moving and handling, first aid, fire safety, food hygiene and infection control. Regulations are adhered to regarding storage and use of hazardous substances, servicing of gas boilers and electrical equipment, temperature of hot water outlets, and window restrictors. The home complies with the legislation listed in standard 42.4 when necessary and the Manager is aware of the requirements. Risk assessments were seen for some areas of the home where health and safety could be an issue. Accident records were seen and proved to be satisfactory. Safety notices and procedures were not posted, but those that had been produced were available to staff in their files or in the office. Induction and foundation training is now based on Training Organisation for the Personal Social Services (TOPSS) specifications. Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 20 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 Standard No Score 1 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 21 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 YA6 Regulation 15 Requirement The registered person must ensure that the information kept about the changing needs of the service users is up to date and relevant. The registered person must ensure that the home is appropriately registered. Timescale for action 01/02/07 2 YA42 YA3 Part 2 (15) Care Standards Act 2000 01/02/07 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 Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ebor Lodge DS0000000883.V319973.R01.S.doc Version 5.2 Page 23 - 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. 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