CARE HOME ADULTS 18-65
Ebor Lodge 92 Westbourne Avenue Hull East Yorkshire HU5 3HS Lead Inspector
George Skinn Unannounced Inspection 24th November 2005 09:30 Ebor Lodge DS0000000883.V262151.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 Ebor Lodge DS0000000883.V262151.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. Ebor Lodge DS0000000883.V262151.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ebor Lodge Address 92 Westbourne Avenue Hull East Yorkshire HU5 3HS 01482 342099 01482 342099 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.V262151.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Ebor Lodge is a large corner house situated in a residential area in the west of the city of Kingston Upon Hull. The house has three floors on which residents 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 residents. 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 residents. The registration category allows the home to care for residents with a mental disorder, excluding learning disability or dementia. Ebor Lodge DS0000000883.V262151.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 which took 3 hours. The home was measured against the national minimum standards for younger adults. Time was spent talking to the residents, inspecting the building and looking at some records. What the service does well: What has improved since the last inspection? What they could do better:
The manager acknowledges that they are not perfect but is always reassessing and auditing the service offered to see if there are areas for improvement. Please contact the provider for advice of actions taken in response to this
Ebor Lodge DS0000000883.V262151.R01.S.doc Version 5.0 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ebor Lodge DS0000000883.V262151.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 Ebor Lodge DS0000000883.V262151.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: Ebor Lodge DS0000000883.V262151.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): 7 The residents are fully involved with the running of the home. EVIDENCE: Conversation with residents revealed that they are able to make decisions about their daily living patterns. Many of the residents handle their own finances, with the home being agents for collection of relevant benefits only. Risk assessments on individual residents indicated any limitations are made in consultation with the residents and in their best interests. Observation made during the inspection indicated that the residents are consulted about many aspects of the homes functioning and choice of meals. Ebor Lodge DS0000000883.V262151.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, 15 & 16 Residents’ take part in their chosen activities, have appropriate relationships and have their rights respected. EVIDENCE: Whilst there are no residents in employment attempt are made to motivate and encourage attendance at the local college for recreational courses. Some residents’ take up these options and details are held in their diary notes. The home encourages residents to maintain links with friends and family, however there is little family contact. The manager stated that past residents visit the home and have meals with them. Two previous residents got married following a friendship which developed in the home. The general routine and structure of the day was observed with staff interacting well with residents, and conversation flowed freely. Keys would be available for residents’ bedroom doors if requested and risk assessment would be made if appropriate.
Ebor Lodge DS0000000883.V262151.R01.S.doc Version 5.0 Page 11 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, 19 & 20 Residents’ preferences are respected and their health and emotional needs are met. EVIDENCE: Written evidence indicated that personal preferences are considered and respected when formulating care plans; this also indicated that the home cares well for residents’ health care needs. Staff recognise when residents 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 Psychiatric Nurses (CPNs). Visits to residents from medical and healthcare practitioners take place in private in residents’ rooms. The home uses the Nomad monitored dosage system for receipting, storing and administering medication. Policies for staff handling medication and for residents to self-medicate are available and are known by the staff. Facilities are provided for residents 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.
Ebor Lodge DS0000000883.V262151.R01.S.doc Version 5.0 Page 12 Proper procedures are in place for the handling of medication following the death of a resident. Records for receipting, storing, administering and returning medication are satisfactorily maintained. Ebor Lodge DS0000000883.V262151.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): 22 & 23 Residents’ were confident that any complaints made would be dealt with appropriately. EVIDENCE: The residents were aware of whom they should complain to if they had any concerns. 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 address and telephone number are included in this. The home has a copy of the East Riding of Yorkshire Vulnerable Adult Guidance manual. The home has a whistle blowing policy. The home has produced a procedure to include guidance for staff to ensure the protection of the residents in their care. The manager has attended the vulnerable adult training and plans to disseminate this amongst the staff. Ebor Lodge DS0000000883.V262151.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): EVIDENCE: Ebor Lodge DS0000000883.V262151.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): 35 Resident needs are met by a well trained and competent staff group. EVIDENCE: 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 residents. A visiting CPN commented positively about the staff and how she was impressed by the level of training which they received. Ebor Lodge DS0000000883.V262151.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 Resident views underpin the running of the home with their safety and welfare being 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 residents views are actively sought on the functioning of the home. 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
Ebor Lodge DS0000000883.V262151.R01.S.doc Version 5.0 Page 17 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.V262151.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 x x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 x x x Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Ebor Lodge Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x DS0000000883.V262151.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. 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. Refer to Standard Good Practice Recommendations Ebor Lodge DS0000000883.V262151.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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