Inspection on 11/02/07 for Elliot Lodge

This inspection was carried out on 11th February 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elliot Lodge 11/10/07

Elliot Lodge 07/06/06

Elliot Lodge 27/01/06

Elliot Lodge 30/08/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Elliot Lodge 4 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QB Lead Inspector Sarah Bennett Key Unannounced Inspection 11th February 2007 13:05 Elliot Lodge DS0000062618.V325148.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 Elliot Lodge DS0000062618.V325148.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. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elliot Lodge Address 4 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QB 0121 444 0187 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) South Birmingham Primary Care Trust Family Housing Association Limited Janet Milutinovic Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A qualified nurse must be working in the home at all times and must not have responsibility for any of the other Newholmes bungalows. Six people with a learning disability under 65 years in receipt of nursing care. 7th June 2006 Date of last inspection Brief Description of the Service: Elliot Lodge is a purpose built care home, on the site of the former Monyhull Hospital. The home is owned by Family Care and Housing, and the care and staffing is provided and managed by South Birmingham Primary Care Trust. The accommodation comprises of a communal lounge, dining room, kitchen, shower room, assisted bathroom, wc, laundry, and six single bedrooms. A qualified nurse is on duty across the twenty-four hour period. They are supported by a minimum of three care staff during the day, and one care staff at night. The home is conveniently located for Kings Heath and Kings Norton. There are good public transport links. The home has a vehicle towards which the service users contribute financially. The statement of purpose stated that the fees charged are £127.35 per week payable to Family Housing Association. The CSCI inspection report is available in the home for those who wish to read it. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. This was the homes second key inspection for the inspection year 2006 to 2007. This unannounced key inspection was undertaken by one inspector over one afternoon. The staff on duty and the Manager were spoken to. Conversations with service users were limited due to their complex needs and limited verbal communication. The inspector met with all service users and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: What has improved since the last inspection? At previous inspections this home has been one that the CSCI had been concerned about. It was good that since the last inspection many improvements had been made and the risks to people living in the home have decreased. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 6 Staff have started to find out what each person likes to do and how their care and support needs should be met. The Speech and Language Therapists have helped with this by developing communication passports for each person. They show how each person communicates including non-verbal communication, gestures and facial expressions. The people living in this home have complex care needs. The care plans and risk assessments were clearer so that staff know how to support each person. Staff records showed that staff are fully checked before they start working at the home to make sure they are suitable to work with the service users. Staff are supported well by their manager so they know how to do their job and how they support each person who lives at the home. The variety of food offered had improved. Records did not show that enough fruit and vegetables were always offered but this had got better. The home now had a new minibus so that service users can do more activities in the community. People get the medication they need at the right time. Staff are checking this more often to make sure this always happens. What they could do better: Before a person moves into the home a detailed assessment of their needs and gaols must be done. Records of this must be kept to show that the home is able to meet their needs. Care plans must include all the needs of the person not just concentrate on their health needs. More activities have been provided in the community. These need to be increased inside the home. Providing a sensory room in the room where the office used to be will help this. Since the last inspection there had not been much more work done on improving the environment. Further redecoration, refurbishment and refurnishing is needed to make sure that it is homely and comfortable for people to live in. Daily records must clearly say how the person has been, what they have done and if staff need to do anything in the next shift to make sure they support them well. All food must be wrapped properly and stored in the right way so that it is safe to eat. Chopping boards that are scratched must be replaced so that food is prepared hygienically. Any food that is out of date must be thrown away. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 7 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. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 8 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 Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 9 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): 1, 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about whether or not they want to live there. Prospective service users needs are not fully assessed to ensure that the home can meet their needs. EVIDENCE: The statement of purpose of the home was reviewed in July 2006 and included all the relevant and required information. Each service user had a service users guide in their bedroom so they are aware of what the service provides. One service user moved into the home in June last year. In their records there was a care plan written by their social worker in 2001 before they had respite breaks at their previous placement. Some information about their individual needs were forwarded to the home by staff from their previous placement. Staff said that there were meetings with staff from the individual’s previous placement and the community nurses before they moved into the home. There was not evidence of an assessment completed by the home prior to their admission. A detailed assessment must be completed before a service user moves into the home to ensure that staff can support them to meet their needs and achieve their goals. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans have improved so that staff have most of the information they need to meet individual’s needs. Service users are supported to make decisions about their lives as much as they are able to. Service users are supported to take risks within a risk assessment framework to ensure that they are safe. EVIDENCE: Two service users care plans were sampled. Since the last inspection care plans had been developed and were written in a way that were centred on the individual and their likes, dislikes, needs and goals that they want to achieve. They stated the individual goal and how staff are to support them to meet it. The Manager said that the Speech and Language Therapist (SALT) has been involved in developing communication passports for all service users. Care plans for communication include details of how the individual communicates Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 11 including non- verbal communication, gestures and facial expression. The SALT had also been involved in reviewing care plans for dysphasia (difficulty in swallowing) where this was appropriate. All care plans were detailed, they had been reviewed monthly and updated where needs or goals had changed. One of the care plans sampled was based mainly on individual’s health needs. Although this is a nursing home therefore the primary needs of individuals is their health needs. However, it is necessary to include in care plans how to meet individual’s social and leisure needs so that the care plan is holistic. Some group service users meetings are held and other individual meetings are held top enable service users to be consulted with and to make choices. They are supported to make choices about holidays, developing the sensory room, health needs, buying things for and decorating their bedrooms and communal areas and what they would like for Christmas. Service users are also informed of the complaints procedure for the Trust and Family Housing. SALT’s involvement in communication passports helps to encourage service users to make choices. Each service user had individual risk assessments. These stated how staff are to support individuals to minimise the risk when bathing or using the shower, using bed sides, if there is a fire, when eating, mobility, when using the hoist, in the minibus, with pressure relief and care of individual’s skin and when asleep. All risk assessments were detailed and reviewed monthly. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. Arrangements have improved so that service users are generally supported to experience a meaningful lifestyle. Arrangements are generally sufficient to ensure that service users have a healthy diet and enjoy their meals. EVIDENCE: One service user goes to a day centre from Monday to Friday. Two service users went out for a walk with staff to a local park. Staff said that there is a roundabout there that you can put wheelchairs onto so that the service users can experience going on this. Staff ensured service users were wrapped up warm, as it was a cold day. When they came back, one service user said, “nice walk, it’s cold out there but warm in here.” Service users records sampled included the activities that they had taken part in. For one service user in the previous week these were: observing staff Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 13 cooking, listening to music, watching TV, spending time in the garden watching the snowman being built, helping to prepare food, helping with the laundry and having a foot massage. One entry said that there were no activities due to the snowy weather. Some activities could have been arranged inside during the bad weather but records did not indicate this. The other service users records sampled stated that they went to the day centre, to a bingo club with another service user, helped to build the snowman, sensory bath and watched TV. Staff said that two service users went to the cinema during the week and enjoyed it. Staff said that the office is being moved into the room off the lounge so that the current office can be changed into a sensory room to provide an alternative activity for service users inside the home. A new minibus had been provided to enable service users to access the community that is accessible to service users. There are three staff that can drive the minibus, one of whom is the manager. Service users are not able to use taxis, as their wheelchairs are too big so more drivers would enable service users to access the community more often. Staff supervision records sampled included discussion about activities for service users including joining a social club, going to the cinema, bowling and going to a club for those of Afro – Caribbean background. Staff said that three service users went on holiday to Somerset last year. Staff said that they are planning to support service users to go on a day trip to Blackpool. One service user said that they would like to go to Cornwall and they enjoyed a holiday in Spain a couple of years ago. Records showed that service users are supported to keep in contact with their family and friends where appropriate. One service user has a relative who lives abroad, they had been supported by staff to buy a postcard of an English post box to send to them. Records sampled included details of staff supporting individuals to take part in household tasks including helping with the cooking, the laundry and cleaning their bedrooms. Records showed that staff support service users to be as independent as possible. Food records sampled showed that a variety of food is offered. On some days the recommended five portions of fruit and vegetables had been offered but Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 14 these had not been offered every day. The dietician had been involved in planning the menu. The menus included an alternative to the main meal so that choice is offered. The kitchen cupboards were well stocked with food. Some fresh vegetables and fresh fruit were available as were a choice of drinks. A traditional roast Sunday dinner was cooked. Staff were observed talking to service users throughout the meal making it a social occasion. One service user said to staff at the end of the meal “thank you for my dinner”. Staff made a drink after the meal for service users and asked what individual’s wanted to drink. The dietary recommendations for individuals were laminated in the kitchen. Staff said that these are going to be laminated into placemats so if agency staff are on duty they will know what each person needs i.e. how many spoonfuls of thickener a person needs in their drinks to aid their swallowing without choking. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 15 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, 21 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 to undertake personal care each day, as they require and are supported to present themselves in a way that reflects their gender, culture and age. Health care is well planned to ensure service users needs are consistently well planned for and met. Medication is well managed, which ensures service users get the right medication at the right time. Completing individuals end of life care plans will ensure that the ageing, illness and death of individuals are handled with respect and as the person would wish. EVIDENCE: All service users were well dressed in clean, comfortable clothes. They had individual styles of dress that were appropriate to their age, gender, cultural background and the activities they were doing. All service users use wheelchairs inside and outside the home. These are designed for the individual and all wheelchairs were clean and well maintained. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 16 Care plans stated how individuals are to be supported with their personal care and to meet their health needs. Staff were observed supporting individuals well and appropriately when they had had an epileptic seizure supporting them to rest, ensuring they were warm enough and had sufficient drinks . One service user did not like being in the dining room as the blender was on and was noisy. A member of staff was observed taking the individual to the lounge and sitting with them looking out the window and talking to them to calm them down. Care plans stated what individual’s ideal weight is and how staff are going to support them to reach this. Staff weigh service users monthly and keep a record of this so they know if an individual is gaining or losing too much weight. Service users records sampled showed that other health professionals are involved in the care of individuals where appropriate and staff support individuals to attend health appointments. Service users have regular eye tests and check ups with the dentist. Records included details of appointments attended and the outcome of these so that staff are aware of any follow-up care needed for individuals. Records showed that relatives are informed of individuals health needs and if a service user has to be admitted to hospital staff support them during their admission so that they are with someone who is familiar with their needs and communication skills. Service users have individual health action plans. These were produced using pictures making them easier to understand. They included details of the individual’s annual health review. Service users records sampled showed that they have regular reviews of their medication to ensure that this is positive in meeting their individual health needs and is not taken if it is not needed. Care plans stated how individuals like to take their medication and if this is to be taken with food to disguise the taste a multi-disciplinary team of health professionals agreed this. The qualified nurse on duty gives the medication to the residents. Medication is stored in a locked cabinet. A separate cabinet is provided for the storage of controlled drugs (CD’s). These had been checked and signed for in the CD register at each handover. The non- blistered medication is audited and recorded at the handover of each shift to ensure that it is being given as prescribed. Medication Administration Records had been signed appropriately and these cross-referenced with the blister packs indicating that medication Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 17 had been given as prescribed. Where service users were prescribed PRN (as required) medication protocols were in place stating when, why and how much of the medication should be given to the individual. Sadly, one of the service users parents had recently died. Records showed and staff said that they had supported the individual to buy some new clothes for the funeral and to go to it. Staff said that quite a few staff also went to support the service user and their family. Care plans included a section for an ‘End of Life Plan’ however these had not been completed. These need to be completed so that individuals are supported appropriately and sensitively when they near the end of their life as they have been through it. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 18 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. Arrangements are in place to ensure that service users and their representatives views are listened to and acted on. Arrangements are in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: Service users records sampled included a copy of the Trust complaints procedure in picture format to make it easier to understand. There was also a copy of Family Housing complaints procedure. Service user meeting minutes showed that staff explained the complaints procedure to individuals helping them to understand how to make a complaint if they are unhappy with the service provided. There have been no complaints received about the service by the home or the CSCI in the last twelve months. Service users financial records sampled showed that their money is only spent on personal items. Receipts were kept of all purchases. Each service user had an inventory of belongings so it was clear what belonged to each person and it is easier to track if items should go missing. These were regularly updated when individuals had bought new things. The Manager said that they are trying to get the signatories changed on all service users bank accounts so that service users money can be accessed easier when they want to spend it. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 19 Staff training records showed that all staff had received training in adult protection and the prevention of abuse. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 20 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, 26, 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the premises but further improvement is needed to ensure that it is a homely and comfortable environment for the service users to live in. EVIDENCE: At the last inspection the lounge had recently been redecorated. The curtains had still not been replaced. They did not match the redecoration and the curtain rail was hanging off the wall. The lounge carpet had been replaced. There were no lampshades in the lounge and by late afternoon when it was getting dark the lights in the lounge had to be turned off as service users were looking up at the lights, which was uncomfortable for them. The lamps were put on around the room and although this made the room look homely and relaxing adequate lighting was not provided. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 21 Staff said that the office is being moved to the room off the lounge and the office is going to be used as a sensory room so offering an alternative activity and space for service users to spend time in. The office carpet was very stained and the office was in need of redecorating. Therefore, as well as providing sensory equipment this room must also be redecorated and the flooring must be replaced. It is planned that the kitchen be refurbished but this had not yet been completed and must be done as the cupboards are worn and some of the worktops were burnt. Service users bedrooms were well decorated and furnished. They were very personalised and decorated according to individual tastes and interests. The bathroom has a range of sensory equipment in it including bubble tubes, a projector that projects images around the room, lights and music. Staff said that service users enjoy spending time in the bath and it is a relaxing experience for them. A shower room is also provided so that service users have the option of a shower or bath. A shower trolley and ceiling track hoist is provided so that staff can support individuals safely. A separate WC is provided that is mainly used by staff and visitors. The decoration in here was worn and it was in need of redecoration. The garden was well maintained. There is a large grassed area and wooden garden furniture, wind chimes and pots on the patio area. The home was clean and free from offensive odours. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 22 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): 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing, their support and development ensure that service users individual needs are met. Service users are supported by the home’s recruitment practices. EVIDENCE: The staff team is generally well established, and consists of people who have got to know the service users well over a period of years. The Manager said that there is one full-time staff vacancy. A qualified nurse and three care staff were on duty as required to meet the needs of service users. Staff rotas sampled showed that the minimum staffing levels had been met. Staff meeting minutes showed that these are held regularly and meet the standard that there should be at least six meetings per year. Staff discussed activities and holidays for service users, input from other health professionals and meeting individuals health needs, contact with relatives and feedback from parents coffee mornings held, parties to celebrate special occasions and training. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 23 Three staff records were sampled. These included the required recruitment records including evidence that a satisfactory Criminal Records Bureau (CRB) check had been received to ensure that suitable people are employed. Recruitment records for qualified staff were not available for inspection. Staff training records showed that staff had received training in care planning, record keeping, epilepsy, PEG feeds, sexuality, adult protection and the prevention of abuse, moving and handling, dysphasia, food hygiene, first aid, sight loss and the Learning Disability Award Framework (LDAF) training. Staff had received an induction when they first started working at the home to get to know the needs of service users and how to support them. Records showed that staff had received regular, formal, recorded supervision sessions with their manager. In these meetings they had discussed the individual needs of service users, the role of the key worker and identified their training and development needs. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 24 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, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements ensure that service users benefit from a well run home. Arrangements are in place so that service users views underpin all selfmonitoring, review and development by the home. Service users records do not always evidence that their rights and best interests are safeguarded. Arrangements are generally sufficient to ensure that the health, safety and welfare of service users are promoted and protected EVIDENCE: The home has a Registered Manager in post, who is a qualified Learning Disability Nurse. It was positive to see that as at the last inspection a Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 25 significant amount of work had been undertaken, or commenced since the last inspection. Many of the requirements from the last inspection had been met. The Trust has a quality assurance system that considers the views of service users and their representatives. Records showed that an audit was completed in December 2006. The Trust and Family Housing had undertaken regulation 26 visits. Reports of these had been forwarded to the CSCI. The required records for regulation are maintained. Some daily records sampled stated “ her usual self this pm” and “ ok this am, no problems.” These are not clear or detailed enough to enable other staff to know how to support the individual or do not evidence that the individual’s needs have been met. Staff training records showed that staff had received training in record keeping. In an unsealed carrier bag in the freezer there was a joint of pork, the packet of which was opened. Staff were asked to dispose of this as it had not been wrapped properly so it was at risk of being contaminated and could have caused food poisoning if eaten. Some vegetables in the vegetable rack looked past their best and needed to be thrown away. Some of the chopping boards were very scratched and could harbour dirt so need to be replaced. Records showed that a Corgi registered engineer tested the gas equipment in March 2006 and stated that the cooker hob was in poor condition. However, this had been replaced. Records showed that the hoists and slings had been regularly serviced to ensure that they are safe to use. Risk assessments for the premises had been developed. Individual staff risk assessments for known disabilities or individual needs had been developed to ensure that all possible support, and control measures are offered. These were detailed, dated and reviewed. Fire records showed that staff test the fire alarm and emergency lighting regularly to make sure they are working. A fire risk assessment was in place to ensure that the risk of a fire starting is minimised as much as possible. Individual fire risk assessments for service users were in place. All staff had received fire safety training in the last six months. Fire drills are held regularly so that staff and service users know what to do if there is a fire. An engineer regularly services the fire equipment. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 26 Staff test the water temps weekly to make sure they are not too hot or cold. The recent records of these showed that these were between 38 – 41 degrees centigrade. The recommended safe temperature is 43 degrees centigrade. Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 27 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 3 2 2 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 1 25 x 26 3 27 2 28 2 29 3 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 x 3 x 2 2 x Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 28 Yes 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. 2. Standard YA2 YA6 Regulation 14 (1) (ad) 15 (1) Requirement A detailed assessment must be completed before a service user moves into the home. Care plans must include how the social and leisure needs and goals of individuals are to be met. Unmet from the previous three inspections. Service users must be offered a range of interesting leisure opportunities inside the home. Service users must be offered the recommended five portions of fruit and vegetables each day. Individual’s ‘end of life’ care plans must be completed. Unmet from the previous two inspections but further progress had been made. All communal areas of the homes registration must be available for service users to use. The room must be redecorated, the flooring replaced and sensory equipment purchased so the room can be used by service users. DS0000062618.V325148.R01.S.doc Timescale for action 31/03/07 30/04/07 3. YA13 16(2)(m, n) 31/05/07 4. YA17 16(2)(i) 30/04/07 5. 6. YA21 YA24 15 (1) 23(2)(e) 31/05/07 30/06/07 Elliot Lodge Version 5.2 Page 29 7. 8. 9. 10. 11. YA24 YA24 YA24 YA24 YA34 16 (2) c 23 (2) (p) 23 (2) (b, c) 23 (2) (b, d) 19 New curtains must be provided in the lounge and the curtain rail must be replaced. Lampshades must be provided in the lounge. The kitchen must be refurbished. The WC must be redecorated. Records not available to assess. The manager must ensure all qualified staff have current professional registration. Daily records must be detailed and clear and state how individuals needs have been met. All food must be wrapped and stored appropriately. Out of date food must be thrown away. The scratched chopping boards must be replaced. 15/04/07 31/03/07 30/06/07 31/08/07 12/02/07 12. YA41 17 (2) 31/03/07 13. 14. 15. YA42 YA42 YA42 13 (4), 16 (2) (j) 13 (4), 16 (2) (j) 13 (4), 16 (2) (j) 12/02/07 12/02/07 30/04/07 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 Elliot Lodge DS0000062618.V325148.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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