Inspection on 21/06/05 for Elsdon Mews (26)

This inspection was carried out on 21st June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elsdon Mews (26) 16/02/09

Elsdon Mews (26) 15/02/08

Elsdon Mews (26) 16/02/07

Elsdon Mews (26) 09/03/05

Elsdon Mews (26) 07/09/04

Elsdon Mews (26) 16/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 26 Elsdon Mews Hebburn Tyne & Wear Address 3 NE31 1RE Lead Inspector Nic Shaw Announced Tuesday, 21 June 2005 : 10:00 st 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 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 Stationary 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. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elsdon Mews Address Hebburn, Tyne & Wear NE31 1RE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 483 3936 0191 483 9747 Northgate & Prudhoe NHS Trust Mrs Agel Hall PC Care home only 8 Category(ies) of 8 x LD registration, with number of places 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th March 2005 Brief Description of the Service: 26 Elsdon Mews provides ordinary housing for people with learning disabilities, many of who were formally resident in long stay hospitals. Elsdon Mews can provide personal care for 8 people who have a learning disability. The service cannot provide nursing care. The home is a purpose built bungalow and due to its design and layout the home blends in well with other properties in the community. The house has two diningroom/lounges, a kitchen/dining area, and eight bedrooms. There is a garden to the rear of the home which service users can access safely. The home has wide passageways and is accessible to people who use wheelchairs. There are seperate laundry and storage facilities. The home is situated close to the town centres of Hebburn and Jarrow and within close proximity to a range of local amenities and facilities. There are bus stops nearby which link with the main regional centres and the home has its own transport . 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours in June 2005 and was a scheduled announced inspection. The inspection process involved obtaining information from relatives on the quality of the service through questionnaires, observing interactions between the staff and the people who live in the home as well as talking to the service users and staff. A sample of records were examined including care plans, rotas, accident book and fire logbook. A tour of the building took place, which included all communal areas and a sample of service users bedrooms. The judgements made are based on the evidence available on the day of the inspection. What the service does well: The staff understand the needs of the people who live in the home and have worked hard to improve how they communicate with them. A good example of this is a special bag containing a grooming kit, which has been purchased for one service user. When they are shown this bag they know that they will be going to visit the horses. Staff are continually provided with training so that they are able to meet the needs of the people living in the home. There is very little turnover in staff which means that the service users benefit from continuity of care. The home provides a safe and comfortable environment. Service users bedrooms are attractive and reflect their likes and preferences. Staff actively involve the service users in taking part in activities both in the home and in the local community and are enthusiastic about looking for new activities, which the service users may enjoy. Relatives are very satisfied with the care provided to their family members and the staff help the service users to maintain contact with their family and friends. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Special baths need to be provided so that the service users are able to safely have a bath. The effect of the behaviour of one person living in the home on the health and general well being of all of the service users must continue to be addressed by the manager. Service users have access to two lounge/dining areas, however, due to the number of service users living in the home and their high level of need the environment does not have suitable space where people who present challenging behaviour are able to express themselves without impacting upon the other people living in the home. Sometimes, due to staff illness, there have only been three staff on duty. When this happens none of the eight service users are able to go out. The manager must therefore make sure that enough staff are on duty when all of the service users are at home. Also, one service user needs constant supervision in order to keep them safe. The number of staff on duty needs to be reviewed to ensure this. Some of the records need to be improved. This includes the Statement of Purpose so that prospective service users know that Elsdon Mews is the right home for them. Care plans also need to be improved so that staff know what they should do to meet the service users needs. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 7 The views of the service users, their relatives and advocates on the quality of the service provided needs to be sought. This information should then be used to help to improve the service. 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. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1&5 Full information is not available to prospective service users therefore they are not able to make an informed decision as to whether or not to move into the home. Service users rights are promoted and protected. EVIDENCE: There is a Statement of Purpose and a Service User Guide. A copy of these are held on each of the service user’s personal files. However, an examination of the Statement of Purpose indicated that this document needs to be developed further. For example, instead of providing details of staff training the reader is advised to view the staff training file. Similarly, any criteria used for admission to the home is not provided, instead, reference is made to viewing the “community home working procedure”. A copy of the contract, which has been provided to each of the service users, is held on their personal file. Minor amendments need to be made to this document, for example, specifying the arrangements for reviewing the service users needs. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7&9 The health and personal care needs recorded in the care plans generally reflect the service users care needs. However, these need to be more detailed to ensure that the service users needs are fully met. The policies, procedures and care practices support and enable service users to take reasonable risks as part of living and independent lifestyle. EVIDENCE: Information was available in care plans to advise staff of the interventions needed of them to meet the service users personal care needs. However, discussion with the staff and observations made of the specific behaviours of a service user indicated that some of the care plans need to be further developed to clearly advise staff of action they should take particularly in order to prevent a service user from harming themselves. As a result of one service users behaviours, and identified risks associated with them, it is not possible for any of the service users to have curtains or 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 11 cushions in their home. Observations made during the inspection clearly indicated that the behaviour of this service user can at times cause distress to the others living in the home. This means that sometimes they may not be able to spend time in the communal lounge. As a result of these concerns the manager has involved an independent advocate who is to work with each of the service users in order to gain an insight into the impact this may have on their health and well being. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,13, &15 Opportunities are provided for the service users to develop independent living skills, become part of the local community and maintain links with their relatives as part of living valued fulfilled lifestyles. EVIDENCE: Discussion with the staff and observation made of care practices concluded that the service users are encouraged to help with activities in the home, such as clearing cups away from the table, cleaning the windows and vacuuming as part of developing their independent living skills. However, the records viewed did not support these positive practices and this is an area for future development. Records examined and discussion with staff confirmed that the service users are supported to take part in activities in the local community. Two of the service users attend Scope, a day service, where opportunities are provided to make craft items, and to take part in activities in the local community such as line dancing. Although the home has its own transport as part of promoting 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 13 community involvement for the people living in the home, staff also support the service users to access public transport. The manager described a recent situation where a service user was supported by staff to travel by train to their holiday destination, a new experience for them, which they enjoyed. Staff spoken to confirmed that they have received training in relation to the Disability Discrimination Act. Discussion with the staff and examination of records confirmed that service users are supported to maintain links with their family and friends. There are no restrictions on visiting times. One service user has a friend who regularly visits them and staff stated that other service users are supported by the staff to regularly visit their family members at home. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 18&20 The home assists service users to be physically and emotionally healthy. EVIDENCE: The level of support each service user requires is recorded in their care plans. Care plans confirmed that the service users have regular access to their GP and other medical professionals, such as physiotherapists and occupational therapists. Staff discussed how hospital appointments take place, which always involves practical support and interpretation of medical conditions. This was observed in practice on the day of the inspection. An aromatherapist was visiting the service users on the day of the inspection, which is a regular weekly appointment. Observations confirmed that staff provide service users with support in relation to their intimate personal care in a sensitive, discreet manner, carrying out care tasks in the privacy of the person’s bedroom. Continuity of care is provided through a keyworker system. Staff spoken to clearly understood their responsibility as the keyworker, which includes the continued development of the communication dictionaries, as well as supporting the service users to buy personal items, such as furniture for their bedrooms. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 15 Medication policy and procedures are in place, which covers storage, handling and administration. The records of medication held at the home accurately matched the numbers held in stock. The manager stated that the supplying pharmacist had recently visited the home to check the storage arrangements and confirmed that they were satisfactory. Discussion with the manager confirmed that staff who are responsible for the administration of medication have undertaken certificated training in ‘Safe Handling of Medication’. Advice was given as to how the records could be improved and this was addressed by the manager at the time of the inspection. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 22 The home has a complaints system, which service users and relatives use if they are unhappy with any aspect of the service provided. This means that relatives and service users know that their views will be listened to and acted upon. EVIDENCE: Service users are not able to tell the staff or manager when they are unhappy or want to make a complaint. However, during the inspection they were noted to express their views and preferences to staff by use of non-verbal communication, including noises and gestures. One service user communicated that they were unhappy. The staff were able to explain the reason for this and responded to his expressed needs appropriately. Questionnaires received prior to the inspection from relatives confirmed that they were aware of the home’s complaints procedures and that they would have no hesitation in making a complaint if they had any concerns. Records examined concluded that there have been no complaints since the last inspection. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 17 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 standard(s) 24,26&27 Service users live in a homely, comfortable environment, which is also clean and warm. Toileting and bathing facilities promote the privacy for each service user, however, not all of the service users have been provided with the specialist bathing equipment they need. Consequently their preferences and choices in relation to their personal care needs are not being fully met. EVIDENCE: The home was found to be clean, warm and well maintained. Each service user has their own bedroom and those seen were spacious and personalised to reflect their likes and tastes. The toilets and bathrooms are lockable, providing privacy for the service users. However, there is no specialist bathing facility. Discussion with the staff confirmed that as a result of this some of the service users, who like to have a bath, are not able to do so. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34&35 The service users are safely cared for by competent and appropriately trained staff. At times staffing levels are insufficient which means that the social and leisure needs of the service users are not being fully promoted and realised. Staff records are not held within the home and as such it was not possible to confirm that the service users are supported and protected by the home’s recruitment practices. EVIDENCE: At the time of the inspection the manager and four care staff were on duty. However, discussion with the staff and records examined concluded that at times, due to staff illness, there have been only three care staff available. When this has been the case, due to the high care needs of the eight service users living in the home, they are unable to take part in any activities outside of the house. Records examined, discussion with the manager and observations during the inspection concluded that due to the challenging behaviour of one service user, and the risks associated with this behaviour, 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 19 they require constant staff supervision. The manager and staff spoken to confirmed that at times this has not been possible to achieve. The “enabler”, who is employed by the organisation on a full time basis to support service users with leisure and social activities in the community, is currently off work. Cover has not been provided in the meantime, which means that some of the service users have not been able to take part in their regular weekly leisure pursuit. For example, one of the service users who usually goes swimming on Tuesday had to remain in the home. Discussion with the staff confirmed that they have been provided with a range of ongoing training from the organisation to support service users and meet their needs. In addition to NVQ level 2 training in care, this has included person centred planning, computing skills, and effective communication with the service users. There are no staff recruitment records available to inspect in the home as required by the Care Home Regulations but these are available at the organisation’s main office. As such it was not possible to fully assess the staff recruitment procedures in order to ensure that they are robust and protect the service users. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39&42 The health and safety of the service users is promoted and protected by a well managed staff team. However, systems for obtaining the views of the service users and their relative’s on the quality of the service provided need to improve to promote and safeguard the service users rights. EVIDENCE: The organisation has a quality assurance system in place entitled “Total Quality Management”. However, the manager stated that this has not recently been implemented, which is an issue that needs to be addressed. There was no evidence available to indicate that service users or their relatives have been consulted on the quality of service provided and this is an area for future development. On the day of the inspection the home was generally free from noticeable hazards, apart from the lounge door, which was wedged open. This was pointed out to the manager who took immediate action to address this issue. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 21 Appropriate records are maintained in relation to accidents. The fire logbook confirmed that staff receive regular fire instruction and drill and that a regular check of fire fighting equipment has been carried out. A random sample of maintenance certificates confirmed that gas and electrical appliances are regularly serviced and tested. Staff spoken to confirmed that they have received training in relation to health and safety matters such as fire fighting, emergency first aid and moving and handling and that this is up-dated annually. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 22 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 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 3 x x x Standard No 11 12 13 14 15 16 17 3 x 3 x 3 x x Standard No 31 32 33 34 35 36 Score x x 2 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 26 Elsdon Mews Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 23 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 1 Regulation 4 Timescale for action The Statement of Purpose must 30th August include all issues identified within 2005. Schedule 1 of the Care Homes Regulations 2001.(Timescale not met 31st May 2005). Service user plans must be in 30th sufficient detail to instruct staff September of the action they need to take 2005. to meet the service users needs. Risk management plans, as 30th discussed and agreed with the September manager, must be developed. 2005. A specialist bathing facility must 31st be provided which meets the December needs of all of the service users 2005. living in the home. Staffing levels must be sufficient 30th August in number in order to meet the 2005. social and lesiure needs of the service users and to promote their safety. Records of staff recruitment 30th August must be available in the home 2005. for inspection.(Timescale not met 31st May 2005). Evidence must be available that 31st the views of the service users, December their relatives and advocates 2005. have been sought and used to develop the service. Version 1.30 Page 24 Requirement 2. 6 15 3. 4. 9 26 13(4)( c )&15 23(2)( n ) 5. 33 18(1)( a ) 6. 34 17(2) 7. 39 24 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc 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. 2. Refer to Standard 5 7&24 Good Practice Recommendations The contract should be developed to include all issues identified within standard 5.2 of the National Minimum Standards. Continued consideration should be given as to how the needs of all of the service users can be met within the current environment. 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Baltic House Port of Tyne South Shields NE34 9PT 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 26 Elsdon Mews B52-B02 S256 Elsdon Mews V219428 210605 Stage 4.doc Version 1.30 Page 26 - 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!