Inspection on 01/11/05 for Elm House

This inspection was carried out on 1st November 2005.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elm House 08/03/07

Elm House 21/06/05

Elm House 11/01/05

Elm House 06/07/04

Elm House 30/03/04

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 Elm House Howitts Lane Eynesbury, St Neots Cambridgeshire PE19 2JA Lead Inspector Andy Green Unannounced Inspection 1st November 2005 10:00 Elm House DS0000015199.V259982.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 Elm House DS0000015199.V259982.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. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elm House Address Howitts Lane Eynesbury, St Neots Cambridgeshire PE19 2JA 01480 471166 01480 471177 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) Brookdale Healthcare Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of six service users under the age of 18 years, but not less than 16 years, in the category LD, to be accommodated in side one of the home No service users over the age of 25 years to be accommodated in side one of the home. No services users under the age of 18 to be accommodated in side two of the home. 21st June 2005 Date of last inspection Brief Description of the Service: Elm House is a home for 12 people with Aspergers Syndrome situated in a large 3-storey house set in its own grounds. The accommodation is presented in two 6 bed roomed self-contained units each with its own kitchen, dining room and lounge. The bedrooms do not have ensuite facilities but there are 8 toilets 2 bathrooms and 3 showers available for service users. There is also a conservatory, which creates further lounge and office space. The home is within walking distance of St Neots town centre and there are shops and facilities close by. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by Regulation Inspector, Andy Green on 1st November 2005 and was the second inspection of the home for the year 2005/6. The inspector met with the manager, care staff and service users. A variety of records were inspected including care plans, medication records, fire records and staff files. A tour of the building was also undertaken. What the service does well: 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. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 6 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 Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 7 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): 1,2,4 Service users have access to good information, and can make an informed choice regarding the home’s services. EVIDENCE: There have been no additions or updates to either the Statement of Purpose or the Service Users Guide since the last inspection. The Manager stated that both of these documents are reviewed as part of an ongoing process to ensure that up to date information regarding the service is recorded. Assessments prior to admission are in place to make sure that that the care needs of prospective service users can be met. The Manager stated that the Multi Disciplinary Team continue to carry out all assessments of prospective service users. The manager stated that this process continues to ensure that consistent and thorough assessments are made. Prospective service users and their relatives can make a number of visits to the home prior to making a decision about whether the service can meet the individual’s assessed needs. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 The care and support provided at the home is of a high standard. Detailed care plans are in place to ensure that staff have sufficient information to satisfactorily meet the service users assessed needs. EVIDENCE: Service users are involved in care planning and reviews and they regularly meet with their key worker to ensure that individual choices, needs and preference are met. Three service user plans were inspected and they contained current information and guidelines to meet the individual’s need including lifestyle plan, activities, and communication guidelines, challenging behaviour guidance and health and safety issues. All records are kept in a clear and accessible format and are reviewed on a monthly basis. Activity Plans are also regularly reviewed with service user involvement. Risk assessments were observed and individual service user are consulted about these assessments. Risk assessments are reviewed monthly, and as required, with input from the multi disciplinary team. The manager also stated that the care planning process has been reviewed to incorporate a new document entitled ‘Care Programme Approach’. This new Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 9 part of the care plan process will be reviewed during the next six months to monitor its effectiveness. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,17 Staff provide appropriate support to ensure that service users have access to activities in the community. EVIDENCE: Service users are involved in a wide range of activities including contact with various sporting venues, an Outward Bound centre and a local Arts Centre. A wide range of community contacts are available to service users and staff offer support and encouragement. There are regular shopping and day trips to local towns and visits to London. Beauty therapy and massage sessions continue to be arranged for a number of service users. Staff are actively involved with service users both in and outside the home and individual preferences are recorded in the service users plan. There is a television, video, DVD and music facilities available to service users. Service users have regular contact with relatives and friends and visitors are welcome at any time according to individual service user preferences. The home promotes individual choice and independence and staff were seen to respect privacy by knocking before entering a service users rooms and assisting service users in a relaxed and social manner. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 11 Communication is proactively and creatively addressed through a variety of methods, which includes pictorial aids where appropriate to the individuals need. Three service users were met during the inspection and they indicated that they were content with the support and services that they were receiving. There is unrestricted access to the home and gardens and service users are able to choose to spend time alone if they wish to do so. The service users help with daily living tasks including menu planning, shopping and food preparation. Individual dietary preferences are recorded in care plans. There are two service users currently budgeting and preparing their own meals during the week. The care staff support service users in the preparation of meals in a relaxed and unhurried manner to suit service users activities and needs. The manager stated that there is a cookery session each week to assist service users to develop and enhance their skills. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Service users receive appropriate health and personal care to meet their assessed needs together with support in taking prescribed medication. EVIDENCE: The staff support service users with personal care needs where appropriate. Each service user has a personal daily timetable regarding daily activities and living skills; these are recorded in the care plan. There is specialist input from the multi disciplinary team on an ongoing basis. Input is also received from an occupational therapist, physiotherapist, CPNs and a psychiatrist. Since the last inspection the home has varied its registration to accommodate up to six male service users from the ages of 16–25 years in side one of the home. Staff spoken to confirmed that it had been a successful development for the home and that they enjoyed working with a younger age group. The home uses a monitored dosage system for drug administration and all staff that administer medication receive appropriate training. The records of medication administered were inspected and found to be accurate. There is a policy regarding medication kept in the home. A pharmacist is available to provide advice when required. Service users health care is detailed in their care plan and reviewed on a regular basis as part of the care planning process. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 13 The manager stated that the home has a good relationship with the local surgery and described GP’s to be responsive to the individual service user’s needs. Care staff support service users to be able to attend out patient appointments when required. Primary health checks are carried out at appropriate intervals and recorded in individual care plans. Elm House DS0000015199.V259982.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): 22,23 The home has a satisfactory complaints process to make sure that service users have their complaints or concerns listened to and acted upon properly. There are suitable arrangements for ensuring the protection of service users from neglect or harm. EVIDENCE: The home has a complaints procedure including agreed timescales to make sure that all complaints are fully investigated and actioned appropriately. The home has not received any complaints since the last inspection. CSCI has not received any complaints regarding the service. The home has a satisfactory policy in place to ensure that service users are protected from abuse. Care staff receive confirmed that they receive ongoing training to ensure that they are aware of adult protection principles and procedures. It was observed that care staff spoke to service users in a friendly and respectful manner appropriate to the individual’s needs. Elm House DS0000015199.V259982.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): 24,25,26,30 The environment is homely and clean and suitable for the needs of those living in the home. Some improvements to the premises need to be made. EVIDENCE: The premises are suitable for the service user’s needs and remain accessible, safe and regularly maintained. The home is comfortable, bright, airy and clean. The furnishings and fittings are of good quality. There is maintenance and redecoration programme and service users are able to choose colours for their bedrooms. The bedrooms are decorated and furnished to meet the preferences of each service user. A television, DVD and video are available for service users to use in the communal lounge. One bedroom has been redecorated since the last inspection. There are some areas however, of the home that needs redecoration and refurbishment including doorframes, walls in the downstairs hallways and to the downstairs toilet wall in side one. The manger stated that these areas would be dealt with via the maintenance department in the next few months. A recent Fire Officer’s report outlined requirements that the home need to meet regarding the provision of appropriate door closing devices and an additional smoke detector. The maintenance department are aware of these requirements and will action them accordingly. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 16 The inspector raised some concerns during the inspection regarding storage and the layout in the office area. It was noted that some files are placed on high shelves, which cannot be reached easily. The layout of the office may also benefit from some attention as staff were observed to be often in each others way when accessing the safes or cabinets. The inspector recommended that the manager, with the staff team, should review the office layout and storage issues. The manager agreed to do this. Elm House DS0000015199.V259982.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): 32,33,34,36 The home’s recruitment policy and processes makes sure that service users are protected from harm. Training is provided to make sure that care staff are competent to deliver care to the service users they support. EVIDENCE: The home’s recruitment policy and processes continue to ensure that service users are protected from harm. Training is provided to make sure that care staff are competent to deliver care to the service users they support. All recruitment is processed through an “Assessment Centre” model. All staff receive a job description which accurately describe the staff’s role. Copies of job descriptions are kept on file. The manager stated that two care posts are being recruited to and one prospective carer is awaiting a suitable CRB check to be completed Staff training is given high priority in the home which is reflected in the individual staff files.Training in mandatory health & safety issues are organised throughout the year along with specific autism spectrum related training. Staff spoken to during the inspection stated that they they continue to receive comprehensive training package . Specialist advice/input is also arranged through the multi disciplinary team, where required, in response to issues raised regarding individual service users care. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 18 Staff are well supported and supervised. Staff confirmed that they received regular individual supervision meetings with their line manager. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,40,42 The home is well managed and the manager provides supportive leadership and guidance to staff to ensure that service users receive high quality care. EVIDENCE: There has been a change of manager since the last inspection and an application to register a manager is being submitted to CSCI. The manager was previously registered as a manager in one of Brookdale Healthcare’s homes and she has relevant managerial and supervisory experience and is near to completing her Registered Managers Award. She creates a supportive and positive approach and communicates a clear sense of leadership and direction to ensure that the home is well managed. Members of staff commented that they felt able to raise issues or concerns freely and that they were encouraged by managers to actively participate in trhe developmwent of the service. Health and safety checks are made and fire safety are accurately recorded Elm House DS0000015199.V259982.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elm House Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X 3 X DS0000015199.V259982.R01.S.doc Version 5.0 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 2 Standard YA24 YA24 Regulation 23 (2) (b) 23 (4) (c) (i) Requirement The premises need to be kept in a good state of repair and decoration The provision of appropriate fire door closers, smoke detectors and fire safety advice must be in place in accordance with the Fire Officer’s requirements An application to register a manager for the home must be made to CSCI Timescale for action 31/01/06 31/12/05 3 YA37 8(2) 31/12/05 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 24 Good Practice Recommendations It is recommended that the manager review the storage and layout of the office area. Elm House DS0000015199.V259982.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Elm House DS0000015199.V259982.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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