Inspection on 02/03/06 for Elgin Lodge

This inspection was carried out on 2nd March 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elgin Lodge 22/03/07

Elgin Lodge 07/12/05

Elgin Lodge 14/02/05

Elgin Lodge 30/06/04

Elgin Lodge 22/02/04

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

CARE HOME ADULTS 18-65 Elgin Lodge 25 Elgin Drive Wallasey Wirral CH45 7PP Lead Inspector Karen Barry Unannounced Inspection 2nd March 2006 12:30 Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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 Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elgin Lodge Address 25 Elgin Drive Wallasey Wirral CH45 7PP 0151 639 3074 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) Pinpoint Developments Limited Mrs Jane Richardson Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Elgin Lodge is registered to provide care support and accommodation for eight adults with a mental disorder. Bedrooms are situated on two floors and comprise of six single and one shared bedroom. Four of the bedrooms have en suite facilities and several rooms have views across the river Mersey. The home is a two storey detached property set in a residential part of the Wirral on New Brighton promenade. The home is within a five-minute drive of Liscard town centre, which has a good selection of shops, banks and a post office. A local bus service is within easy reach of the home. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived at the home without prior notice being given. Time was spent discussing and examining records held within the home with the manager and various staff members. A tour of the home was undertaken and then the inspector spent time in the lounge and dining areas discussing experiences and expectations with residents and staff members. What the service does well: What has improved since the last inspection? No requirements or recommendations where made during the last inspection in order for the inspector to measure any significant improvements made. However it was noted that the staff have continued to support the residents to live their lives as they desire without undue stress and complications. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 6 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. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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 Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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 Assessment completed prior to admission ensure service users identified needs and aspirations can be met effectively via the support and services offered within Elgin Lodge. EVIDENCE: Although no new service users have been admitted to the home since the previous inspection, the inspector examined pre assessment documentation held upon service user’s files. These confirmed that all aspects of an individual’s physical and mental health had been explored and relevant advice and guidance was sought to ensure the staff within the home and the services offered would be appropriate to meet identified needs and aspirations. It was reported during this inspection that one of the service users presently living within Elgin Lodge is awaiting a move to another care home setting as meeting his changing needs and challenging behaviour is having an impact upon the balance of meeting the individual’s needs with the needs of the other service users within the home. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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): 6,7,8,9 & 10 The registered manager and the staff team appear to work hard to make sure the needs and aspirations of the residents are met by having detailed care plans and risk assessments in place. EVIDENCE: Residents confirmed that they are involved in the devising of their own care plans and that the staff regularly discuss methods and strategies used within risk assessment so that they understand reason why any restrictions may have been put it to place and any support they might be offered in order to reach any new goals set. A key worker system remains in place within the home in order to assist staff members in undertaking their roles and responsibilities of promoting service users independence whilst keeping them safe and well. The inspector examined 3 service users files in order to confirm plans had been reviewed and that they where indeed up to date. Documentation seen indicated that this was the case. There is a policy on confidentiality in place and resident’s files are securely stored within the office, which is kept locked when not in use. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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): 11,12,13,14,15,16 & 17 The resident’s social and personal development opportunities are enhanced by staff members’ facilitating appropriate leisure and work activates and the promotion of participation within the local community EVIDENCE: Residents have access to a range of information leaflets and booklets regarding various places of interest to assist them in planning activities they’d wish to pursue. Staff and house meeting are held regularly to discuss and plan various events and opportunities for the residents. The key-workers system used within the house enables residents and staff to devise individual activities and group social events in and outside the home, which ensure each persons individual hobbies and interests are addressed, this includes providing opportunities to access therapeutic or supported employment if the individual resident agrees this would be beneficial to their personal development. Records seen within various files demonstrated how this is regularly put into practice. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 11 Daily routines are flexible in accordance with the needs and expressed wishes of the residents. Records and discussion with staff and residents however confirmed that the staff themselves strive to provide a consistent approach in relation to the support various individuals require when dealing with any unexpected changes to their daily routines. The home had an unrestricted visiting policy between the hours of 10am and 9pm. Residents can entertain their visitors within the main lounge or if they wish to have a private meeting the can use their bedroom or the visitors lounge upstairs. Observations indicate that residents were treated with respect and dignity at all times by staff members. Varied, wholesome meals are offered within the house which take into account residents preferences and any particular dietary needs that are required. It was noted that the staff team work well together to prepare and cook meals that are served in an unhurried manner within a pleasant environment. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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): 18,19,20 &21 Residents physical and mental health needs appear to be met appropriately in a sensitive, flexible and appropriate manner. Medication and health issues appear to be handled appropriately within Elgin Lodge. EVIDENCE: The majority of the residents within Elgin Lodge require very little if any assistance with regards to meeting their personal care needs, however staff do give verbal prompts as directed within written care and support plans to ensure they any issues or concerns are addressed in a sensitive manner. The manager told the inspector that one of the resident has recently been diagnosed with a deteriorating illness. Records and discussions confirmed that appropriate advice and guidance was being sought from the consultant, GP, Macmillan and district nursing staff to enable the staff within the home to redevise a more suitable care plan to guide them in assisting this gentleman with aspects of his personal and emotional care. Alongside the need to understand the overall roles and responsibilities of dealing with his changing health needs, as certain areas will be over and above the care staffs roles and duties of care. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 13 Polices and procedure used for the receipt, storage, disposal, and documentation of medications within the home appeared to be being followed appropriately by staff members. A sample of medication records where crossed checked against medication held and no discrepancies where noted. The community psychiatric nurse visits most of the residents at regular intervals. All of these visits and any interaction / administration of medication by the nurse is recorded upon the residents file. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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 the following standard(s): 22 & 23 Polices and procedures are in place to ensure residents views are listened to and acted upon and that they are protected from abuse, neglect and selfharm. EVIDENCE: Examination of the home’s complaints book indicated that the home is extremely proactive in recording and dealing with any concerns or complaints raised by residents. There was evidence to show that any such issues have been dealt with in a prompt and professional manner. Residents confirmed that regular house and key-worker meetings take place which ensures their views are taken in to account regarding events and situations that occur. The home has a copy of “Protecting Vulnerable Adults in Wirral”. The manager confirmed that staff members have received relevant information and guidance regarding dealing with allegations of abuse etc. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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 the following standard(s): 24,25,26,27,28, 29 & 30 The home provides a comfortable environment where residents state they feel safe and comfortable. Bedrooms reflect individual choices and preferences. The house appears clean, tidy and very homely. EVIDENCE: All areas of the home where found to be clean and tidy on the day of the inspection. Furnishings and fittings are domestic in style and of a good quality. Toilet and bathroom facilities throughout the home are sufficient to met the needs and requirements of the residents. A programme of redecoration and replacement of fittings is in use within the home. Residents spoken too confirmed that they are involved in the choosing of new items and colour schemes used within the home and that on occasions they have assisted with some of the decorating themselves. Bedrooms viewed reflected individual personalities and preferences. All bedrooms have suitable locks to ensure privacy for the residents. Staff members can override these locks in case of emergency. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 16 During the last inspection staff had indicated that the kitchen was to undergo a refurbishment after Christmas. Unfortunately work on this project has not yet begun. Residents and staff appeared disappointed regarding this work being delayed. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 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 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): 31,32,33,34,35 & 36 Residents are supported and protected by a knowledgeable, experienced staff team. EVIDENCE: Staff members spoken to are fully aware of their roles and responsibilities via their job descriptions and have access to various polices and procedures as required. Inspection of the rota indicates that appropriate numbers of staff are on duty throughout the day and nigh times periods. Although no new staff members have been employed for sometime the inspector examined 3 staff files. Each file contained the required documentation to confirm that robust selection and recruitment procedures are followed. Training certificates are kept within individual staff files and training schedules are managed through consultation with the manager and owners at regular intervals, to ensure all staff members continue to receive relevant training to undertake their roles and effectively. Staff members reported that they felt supported by the manager and confirmed that they do receive regular 1-1 supervision. However they expressed a view that such formal sessions weren’t necessarily required as Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 18 they felt they had opportunities to discuss issues and concerns as they occurred with the manager as she regularly works ‘hands on’ within the home. The inspector discussed these views with both the manager and the staff team and suggested that they considered formal supervision sessions as an opportunity to reflex upon events that had occurred within the home and to record if a similar situation arose again would they react differently and if so why. After examining supervision and annual appraisal records used within the home it was suggested that a shorter version of the appraisal form was used within supervision, as these appear to assist staff members in focusing upon the positive aspects of their personal and professional development. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 19 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, 38, 40, 41, 42 & 43 The home is well managed and run in the best interests of the residents. There is good leadership, guidance and direction to ensure that they received consistent care. The home is well maintained to ensure the safety of residents and staff. EVIDENCE: Observations throughout the inspection indicated that the manager had a good rapport with the residents and staff group. Staff meetings are held regularly and records where seen to show areas discussed and plans for actions to be taken, however it was noted that no formal meetings had taken place so far this year. It’s recommended that dates for such meetings are pre-planned for the year ahead to prevent an oversight relating to when such meetings should be held. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 20 The manager completes quality assurance and audit assessments within the home. These are recorded and discussed with the owners of the home at regular intervals. Elgin Lodge has a set of polices and procedures, which are readily available to residents and staff. The inspector was provided with documentation in relation to maintaining a safe environment, documents seen were relevant and up to date. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 21 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 X 3 3 3 3 Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 22 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. 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 YA41 Good Practice Recommendations Dates for staff meetings should be pre-planned for the year ahead to prevent their importance being overlooked. Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Liverpool Local Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Elgin Lodge DS0000018884.V287032.R01.S.doc Version 5.1 Page 24 - 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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