Inspection on 09/09/05 for Elm Cottage

This inspection was carried out on 9th September 2005.

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 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 7 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 21/02/06

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 12th September 2005 09:45 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 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 Ms Nicola Jane Rabey Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 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) 30/03/2005 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 Registered Manager, Ms Nicola Rabey, manages both homes. 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 to 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.V249099.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on one day in September 2005, over 2 hours. The inspection process included an informal discussion with two members of staff, one service user, observation and examination of records and documents. The service users accommodated at Lucerne Road 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, and brief general discussion, it was clear they had a good relationship with staff and were settled at Lucerne Road. What the service does well: What has improved since the last inspection? What they could do better: The home was in urgent need of external and internal re-decoration, maintenance and repair. The house is beginning to stand out amongst the other houses in the cul-de-sac and did not give an accurate reflection of the 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 6 homes stated purpose or the quality of care provided. The internal décor is no longer inspiring for service users or staff. Statutory requirements and recommendations with regard to environmental issues highlighted in this and the previous two inspection reports remain outstanding. Partnerships in Care had purchased the property, and submitted a planning application for minor alterations to the structure of the property to the local planning department in 2004. No further action has taken place. The Commission continues to await an action plan regarding the future development of the home to address the repeated statutory requirements and meet National Minimum Standards. 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.V249099.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4. The home operates a thorough pre admission process, giving care and attention to ensuring the home is admitting individuals whose entire assessed needs could be fully met. The home promotes the opportunity to visit the home as an essential part of the admission process. EVIDENCE: The service has not admitted any new service users since the last inspection. Previous inspections commended the service for its thorough, comprehensive pre admission process, which met the intended outcomes for prospective service users. Lucerne Rd operates a graded admission policy of visits in progressive duration covering introduction and compatibility with other service users and orientation to the home and staff. The home does not admit unplanned or emergency admissions. The homes manager and the multidisciplinary team, together with the service user and/or their relative and/or advocate, carried out Pre admission assessments, which also included assessments from various specialists. 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care plans were service user focused, developed according to needs, including rehabilitation processes and achievable goals, care and maintenance of health, lifestyle and well-being. Service users were supported within an individualised risk management approach. EVIDENCE: Staff spoken with demonstrated a full understanding of each service users needs and the importance of maintaining thorough and explicit care plans to ensure a consistent approach in the delivery of support to the individual with an ABI, to develop and maintain their rehabilitative state. Care plans were linked to the Care Programme Approach (CPA) and the home worked in partnership with the multidisciplinary team, the service user and/or relative/advocate enabling care to be delivered in an agreed organised way. Regular reviews were carried out to determine effectiveness of the rehabilitative programme, update goals or look at alternatives. 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 10 Comprehensive risk assessments were evident in each service users plan with clear risk management strategies to reduce potential risk individuals with an ABI face on a daily basis due to impaired memory and concentration. Any infringements and limitations to service users choice were made through the assessment process and in the service users interests to prevent harm to themselves and others. This was recorded in the service users Plan, documented under Article 8 of the European Conventions on Human Rights together with a signed opinion of the Neuro-Psychiatrist based on medical evidence that the service user did not have the mental capacity to make informed choices. 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 11 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 Service users were given the opportunities and support to maintain and develop social, emotional, communication and independent living skills in and outside the home. Family and friends links with the service were strongly encouraged and well developed. The home offered opportunities to establish a structured and purposeful lifestyle, respecting service users rights and choices. The home supplied sufficient quality of food and provided a well balanced diet that met individual needs. EVIDENCE: Cognitive problems restrict prospects for individuals with ABI of returning to previous employment, training or lifestyle. One service user was being supported in maintaining their rehabilitative state following recovery. One 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 12 service user was on the community rehabilitation programme looking towards a more independent outcome and is participating in a computer course and a cooking course specific to people with ABI, leisure activities such as swimming and the theatre and maintaining a daily living programme such as shopping, changing the bedclothes and keeping own room tidy. One service user was observed being supported through their planned individualised daily programme of simple activities, aimed to maintain and improve functional performance in every day living skills. The service user said the daily programme was important, and to help with the short-term memory loss they would record each activity in a diary following completion. From care review documentation it was evident service users were facilitated to make decisions with regard to their own life. Freedom of movement within the home was observed and staff were observed giving support to service users to make choices insofar as was practicable to exercise control over their life in accordance to their risk management plan. It was evident the home viewed community access and inclusion essential to the rehabilitative process and was incorporated in accordance with the service users assessed needs and individual plan. Service users were supported on a one to one basis by staff in the community. Important dates were recorded in individual care plans for staff to support the service users in maintaining links with family and friends on birthdays and anniversaries. One service user confirmed regular contact with family. The staff had worked closely with the service users producing menus looking at more healthy options and fresh produce incorporating choice, likes and dislikes. Mealtimes were seen to be flexible around service users choice. 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 13 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 The service users were looked after well in respect of their healthcare and personal needs. Staff engaged positively with each individual and demonstrated a good understanding of the service users they were supporting and treated them with dignity and respect. EVIDENCE: Respectful and helpful interaction was observed between the staff and service users. It was evident within the care plans that the healthcare needs of the service users were clearly seen as a fundamental part of their care and addressed within assessments and reviews. Each service user was registered with the local GP and had access to other Primary Healthcare Professionals. Female service users had access to well woman clinics. 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 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): NOT ASSESSED ON THIS OCCASION. EVIDENCE: 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 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 clean and homely environment although the standard of the décor outside and within the home has deteriorated and is in need of attention. EVIDENCE: The bungalow is located in a small residential setting; the home is beginning to stand out against others in the area due to its poor decorative state. The home was clean and free from offensive odours, domestic in scale providing a homely environment. However redecoration, refurbishment and minor maintenance had not been carried out for some time, carpets were shabby and in need of robust cleaning or replacement. Staff indicated that they had not been updated on the redevelopment plans for the home and redecoration and maintenance had continued to be on hold. They felt this did not provide an encouraging environment for the service users to live in or for the staff to work in. Single accommodation is provided, one room is smaller and did not have sufficient available floor space to include minimal furnishings such as two comfortable chairs and a table, and there are no en suite facilities. 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 16 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. 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. 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 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): 32, 33 & 35 The home had adequate staffing arrangements to meet the service user’s needs. The care staff received sufficient information and appropriate training to support the service users. EVIDENCE: There were three members of staff on duty supporting two service users. One of the staff members was under supervision during the induction process and was shadowing a senior member of staff. From discussion with staff and observation it was evident the staff were committed to the service users programmes of care and demonstrated a good understanding of techniques of rehabilitation, treatment and recovery programmes. Staff spoken with, were generally enthusiastic about the introduction of the inhouse competency framework, which they had recently commenced. A learning programme linked to service aims and service user needs providing the opportunity to broaden specific skills and understanding required for supporting the service users on specific rehabilitation programmes. An initiative to develop and retain a highly skilled workforce. Fifty per cent of the care staff have successfully achieved NVQ level 2 in care. 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 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): The outcomes or NMS for Conduct and Management of the home were not assessed on this occasion and therefore the previous requirement made with regard to quality monitoring and assurance has been carried over. EVIDENCE: 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 4 3 3 X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 2 2 1 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7 Lucerne Road Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000017739.V249099.R01.S.doc Version 5.0 Page 20 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. Standard YA27 Regulation 23 Timescale for action The Registered Person must 31/01/06 provide the option of a bath for the service users. Repeat requirement within timescale. 2. YA30YA28 23 not met Requirement The Registered Person must 31/01/06 provide suitable laundry facilities to include sluicing facilities and a hand washbasin. Repeat requirement within timescale. not met 3. YA24 23 The Registered Person must 31/01/06 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. The Registered Person must 31/01/06 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 DS0000017739.V249099.R01.S.doc Version 5.0 Page 21 YA28YA41 4. 17, 19. 7 Lucerne Road running of the business. Repeat requirement within timescale. 5. YA39 24, 12 not met The Registered Person must 31/01/06 ensure there is a continuous selfmonitoring and quality assurance process in place, which meets National Minimum Standards. Carried over inspection. from previous 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 YA25YA25 Good Practice Recommendations The Registered Person must consider how this standard will be met with regard to adequate available floor space. Recommendation carried over from previous inspection. The Registered Person must consider how this standard will be met with regard to the provision of two armchairs and a table in the bedroom, which does not have available floor space. Recommendation carried over from previous inspection. 2 YA26 7 Lucerne Road DS0000017739.V249099.R01.S.doc Version 5.0 Page 22 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.V249099.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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