Inspection on 21/02/06 for Elm Cottage

This inspection was carried out on 21st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elm Cottage 17/07/08

Elm Cottage 25/01/08

Elm Cottage 30/01/07

Elm Cottage 09/09/05

Elm Cottage 30/03/05

Elm Cottage 07/12/04

Elm Cottage 26/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 7 Lucerne Road Elmstead Market Colchester Essex CO7 7YB Lead Inspector Gaynor Elvin Unannounced Inspection 21st February 2006 15:00 7 Lucerne Road DS0000017739.V284619.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 7 Lucerne Road DS0000017739.V284619.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. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 7 Lucerne Road Address Elmstead Market Colchester Essex CO7 7YB 01206 822794 01206 822794 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) Partnerships in Care Limited Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require by reason of a learning disability (not to exceed 3 persons) 12th September 2005 Date of last inspection Brief Description of the Service: 7 Lucerne Road is a registered care home providing accommodation for three people under the age of 65 years who have an acquired brain injury. It is one of two homes in the area owned by Partnership in Care, which is now part of the Sinven organisation. The home runs two programmes of care: one for community rehabilitation and the other being long term supported living assistance for service users requiring maintenance of their rehabilitative state, who may also present with behavioural problems, which can be managed within the home. 7 Lucerne Road is small, detached bungalow situated in a small residential cul de sac in the village of Elmstead Market, approximately five miles from the town of Colchester. The home is within walking distance of local village amenities, which includes a shop, a pub and the local GP surgery. The village is on the main bus route to the town of Colchester and the seaside town of Clacton on Sea. Single accommodation is provided and a communal shower room. The home has a lounge and dining/sitting room for shared activities. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on one day in February 2006, over three hours. All of the key standards for young adults and the intended outcomes have been assessed in relation to this service during at least two inspections for the current inspection year (April to March). To view the assessment of standards and outcomes not included within this report, please refer to the previous published report dated 12th September 2005. The service users accommodated at Lucerne Rd have sustained an Acquired Brain Injury (ABI) and have varying degrees of permanent cognitive disability following the early stages of recovery. This includes changes in concentration, awareness, perception and insight and in some cases long term and/or shortterm memory loss. Discussion with the service users regarding care delivery was not appropriate. However, during this and previous inspections the service users looked well cared for and from observation of their body language and behaviour it was clear they had a good relationship with the care staff. This inspection focused on the outcomes and National Minimum Standards not assessed in the previous inspection, looking at working practices, supporting documentation and records, as well as progress made in addressing the statutory requirements and good practice recommendations made in the previous inspection report. The home has been without a manager since the departure of the Registered Manager, Miss N. Rabey, in October 2005 and at the time of inspection there had not been any response to the advertised vacancy. Janet Luck, a Service Manager at Elm Park, an independent hospital run by the Registered Providers, Partnerships in Care and regulated by the Health Commission, is overseeing managerial arrangements two days a week. Whilst these arrangements were agreed by the CSCI on a short-term temporary basis, the Registered Providers must now consider full time managerial arrangements for the home by a Registered Manager with knowledge of the National Minimum Standards underpinning the Care Homes Regulations 2001, to provide the essential elements of day-to-day management highlighted within this report and reflected by the increased level of requirements. What the service does well: The home promotes a safe homely environment, supporting the service users in the readjustment and reconstruction of their lifestyle. Staff have worked as a close team and supported each other during a difficult period of change and have ensured minimal disruption to the lives of the service users. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 6 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. 7 Lucerne Road DS0000017739.V284619.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 7 Lucerne Road DS0000017739.V284619.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): Standards 1-5 and their intended outcomes were not assessed on this occasion please refer to previous inspection report dated 12th September 2005. EVIDENCE: 7 Lucerne Road DS0000017739.V284619.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): 10 Staff respect service users confidences and are fully aware of confidentiality issues. EVIDENCE: The homes confidentiality policy has recently been reviewed and updated. The Senior Carer spoken with was aware of the policy and its contents and had recently completed a piece of work in the home’s Competency Framework on confidentiality. Service users’ individual records were appropriately maintained and stored securely to protect confidentiality. 7 Lucerne Road DS0000017739.V284619.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): 17 Staff provided a well balanced diet that met individual needs. EVIDENCE: The care staff also prepared and cooked the meals for the service users. Staff indicated the Aga is ‘horrendous’ to cook on and is particularly difficult for younger staff with limited cooking abilities. The staff worked closely with the service users producing menus, looking at healthier options and fresh produce, incorporating choice, likes and dislikes. Different approaches to promote choice were discussed with staff such as menu picture books to prompt visual perception. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 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): 20 The practice of medication administration was not satisfactory and may potentially cause harm to the service user. EVIDENCE: Service users were unable to retain or self-administer medication. The medication policy reflected all areas of safety. All staff have received accredited training in the safe handling and administration of medication. Care plans reflected individual medication prescribed and included information relating to the side effects and adverse reactions of medicines being taken by the service user, which is good practice. However, medication is dispensed from the GP surgery into Dossett boxes, a system normally used for self-administration. The system provides medicines for seven days. All tablets for a defined administrative time are placed together within the same compartment, making it difficult for the care staff to identify what medication is being administered or even refused. This system deflects from formal reference to appropriate pharmacy computer generated Medication Administration Record (MAR) charts giving correct details of prescription and retrospective signing of the records for safe administration of medication cross referenced with prescription on the MAR chart and tablet container. The cassette was not labelled and did not give details of its contents, dose and frequency. This current practice deflects from the homes policy and procedure 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 12 for the safe administration of medication and is a potential cause of error and harm to the service user. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 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 The home had adopted an open approach to complaints. Staff treated service users with dignity and respect, however a more robust adult protection policy is required to inform staff in the event of any suspicion or allegation of abuse being made. EVIDENCE: The home’s complaints policy and procedure was in place and accessible to the service user’s representatives. Senior staff spoken with were aware of the procedure to take in the event of a complaint being made. Staff indicated that the current service users were not able to make a written complaint but any verbal concerns or complaints would be listened to, taken seriously and acted upon appropriately. The home had not received any complaints since the last inspection. The home had good policies with regard to preventing abuse through good practice and staff and management support systems and how to recognise abuse. However, there was no guidance for staff on what to do in the event of a suspicion or allegation of abuse incorporating Local policy and Essex Social Services alert forms and contact numbers within the corporate policy and procedure. The staff had received in-house Protection of Vulnerable Adults (POVA) awareness training; the senior was advised to access approved training from Essex Vulnerable Adults Protection Committee (EVAPC). 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 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): 24,25,26,27,28,29 & 30. The home provides a clean and homely environment although facilities provided for service users and staff do not meet National Minimum Standards. EVIDENCE: A full inspection of the premises was not carried out on this occasion. However, areas visited were seen to be clean and free from offensive odours, domestic in scale providing a homely environment. Staff indicated that they had not been updated on the redevelopment plans for the home although some redecoration and maintenance was being carried out to the external structure of the building such as painting and replacement of some windows. Comments made during the last inspection with regard to office and laundry facilities have still not been addressed. The small staff office houses the washing machine and tumble dryer and is also used as the laundry room. The service users share one ‘bathroom’, which did not have a bath – only a shower is provided. Consideration has still not been given to installing a bath so that a choice is given. This room was in need of repair and redecoration and it was noted that the sink was cracked and needed replacing. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 15 Due to the layout and small passageways of the bungalow, the home is not suitable for wheelchair users. One current service user requires the use of a walking frame; the service user and staff indicated this proved difficult to manoeuvre at times. The smallest of the three bedrooms did not meet National Minimum Standards with regard to size and the ability to furnish with required minimal furnishings. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Recruitment practices were thorough and promoted the protection of service users. The quality and frequency with which care workers are formally supported does not meet with good practice. EVIDENCE: Staff were deployed across Lucerne Rd and the sister home, Wivenhoe Rd. Between the two homes there are currently six staff vacancies. There is currently only two service users accommodated at Lucerne Rd. Staff indicated that two members of staff per shift were required to meet the assessed needs of these individuals and to maintain this level of staff, usually required, approximately seven shifts per week to be covered by agency staff. The home had not recently appointed any new staff, although interviews were being carried out today at the sister home, by external management from Elm Park, independent hospital. The interview panel did not include a member of staff, currently employed in the homes, with the appropriate knowledge of the service users needs or stated purpose of the service to ensure suitability of prospective staff. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 17 The recruitment files of four members of staff were examined. All the files held evidence of the required checks undertaken including two satisfactory references, evidence of identification and a satisfactory enhanced CRB and POVA first disclosure; with the exception of one file and only one reference had been received. The files also included a completed application form, employment history, a written record of the interview, record of induction and a copy of the Contract of Employment, Statement of Terms and Conditions and a job description. Staff were unaware of a current annual staff training and development plan. From the sample of staff files examined, statutory accredited training in health and safety subjects such as Food & Hygiene, Infection Control, First Aid, Managing Challenging Behaviour and Medication Administration required update. This will be reviewed at the next inspection. Staff confirmed that more than 50 of the small core team had successfully achieved NVQ level 2 in care. Discussion took place with the Human Resource Manager with regard to the introduction in 2006 of Skills for Care compulsory Common Induction and Foundation Standards to be commenced by all newly recruited staff. Staff confirmed that management support is provided to the home by the Service Providers external management team, based at Elm Park. Ms Luck, the service manager attends the home twice weekly and the Health and Safety Manager attends the home once a week. Opportunities are provided to discuss concerns or care related issues, Service User review and household management at a weekly meeting, held by Ms Luck for all staff. Senior staffs indicated that they have endeavoured to support staff by regular practical supervision through daily contact. However a stronger emphasis on frequent, formal and fully documented supervisions is required to reflect all the elements necessary to support staff in developing and sustaining their working practice and identify training and development needs; to be carried out by staff suitably trained in the supervisory process. The responsible person must ensure that more formal arrangements are in place with regard to providing regular supervision for all staff, in addition to providing regular contact on a day-to-day basis, particularly as staff work at times in isolation and the home is currently lacking leadership. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 & 43. The home is currently without a manager and the interim managerial arrangements put in place by the Responsible Person are not robust enough for the home to benefit service users and staff in the long term. EVIDENCE: It is now more apparent that an authoritative style of management was previously experienced and the previous manager ran a tight ship. Since the lack of full time management the senior staff had to take a more active role in the day to day running of the home with very little experience. While the staff expressed appreciation for the help and support received from the Management at Elm Park, it was evident that a more hands on approach to the essential elements of management within the home was required. Concerns were also expressed that elements of working practice from Elm Park were beginning to overlap into a very different caring environment. Elm Park is 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 19 regulated differently and works towards different standards and this may be confusing to some staff. Corporate policies and procedures were in place; they had recently been revised and updated. The staff were currently reviewing and considering their appropriateness to the service. The home’s policy and procedure review group, led by the previous manager, had collapsed since her departure. Staff felt this was a shame as the workings of the group brought a clearer understanding of the guidance and relevance to working practice. Staff were unaware of any quality assurance or monitoring systems. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 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 X 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 2 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 1 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 1 X 2 2 2 X 2 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 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 YA20 Regulation 13(2) Requirement The Registered Person must review the current medication system to reduce the potential cause of error and harm to the service user. The Registered Person must ensure robust procedures are in place for responding to suspicion or evidence of abuse, incorporating local policy and guidelines. The Registered Person must ensure the home has a planned maintenance and renewal programme for the fabric and decoration of the premises and ensure this is carried out with records kept. A repeat requirement not met within timescales 31/01/06 The Registered Person must provide suitable laundry facilities to include sluicing facilities and a hand washbasin. Third repeat requirement not met within timescale. 5. YA28YA30 23 The Registered Person must 01/06/06 provide the option of a bath for Timescale for action 01/06/06 2. YA23 13(6) 01/06/06 3. YA24 23 01/06/06 4. YA27 23 01/06/06 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 22 the service users. Third repeat requirement met within timescale. 6. YA28YA41 17,19. not The Registered Person must 01/06/06 provide suitable and secure office facilities for the staff and storage of records required by regulation to be kept within the home for inspection purposes and for the effective and efficient running of the business. Third repeat requirement met within timescale. not 7. YA35 18 The Registered Person must 01/06/06 ensure there is an annual staff training and development programme, informed by individual and team training needs assessment to ensure staff receive appropriate training and update as required to meet the stated purpose of the home. The Registered Person must ensure that staff receive the support and supervision they need to carry out their jobs. Staff have regular recorded supervisions as required by NMS 36.4. The Registered Person must ensure staff who supervise colleagues are trained and supported/supervised by senior staff. 01/06/06 8. YA36 13 9. YA37YA43 9 10. YA39 24,12. The Registered Person must ensure that service users and staff benefit from appropriate managerial arrangements, leadership and guidance. The Registered Person must ensure effective quality assurance and monitoring systems are in place to review DS0000017739.V284619.R01.S.doc 01/06/06 01/06/06 7 Lucerne Road Version 5.1 Page 23 care outcomes and inform future practice. This is a third repeat requirement not met within previous timescales of 31/01/06, 31/03/05 & 1/09/05. 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 YA40 Good Practice Recommendations The Registered Person should ensure policies and procedures are appropriate to the service. 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 7 Lucerne Road DS0000017739.V284619.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!