Inspection on 27/10/05 for Elstow House

This inspection was carried out on 27th October 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

Elstow House 17/12/08

Elstow House 02/08/06

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Elstow House Elstow House 25 Marriott Street Northampton Northants NN2 6AW Lead Inspector Mrs Kathy Jones Unannounced Inspection 26th October 2005 07:40 Elstow House DS0000063135.V261870.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 Elstow House DS0000063135.V261870.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. Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elstow House Address Elstow House 25 Marriott Street Northampton Northants NN2 6AW 01604 461 292 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) Adenike Adenuga Adetayo Olajide Adenuga Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the home limits its services to the following Service User category: Learning Disability - LD A total of 9 Service Users No person under 30 years of age or above 55 years who falls within categories LD may be admitted to the home 8 August 2005 Date of last inspection Brief Description of the Service: Elstow House care home providing long-term care for nine adults with a learning disability. The home is an established care home, which has recently changed ownership. The home is now owned by Genesis Homes Ltd. Elstow House is close to Northampton town centre and has easy access to the local facilities and services. The home is a three-story town house. Accommodation is provided in single rooms. There is a communal lounge and dining/kitchen on the ground floor and a kitchenette and seating area on the lower ground floor available to the two residents who have bedrooms on that floor. Elstow House DS0000063135.V261870.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 over a four and a half hour period during the morning of a weekday. Prior to the inspection the inspector spent an hour reviewing the last inspection report and the homes history in order to ascertain the key areas to be inspected. The inspection involved talking to residents over breakfast about their life in the home prior to the majority going out to work or day centres. A sample of residents’ records was reviewed to see how their care is planned and supported. Resident’s involvement in the care planning process was discussed with a resident. The inspector met with staff on duty to discuss the care provided and how residents are protected. Records reviewed included a sample of staff recruitment and training records. What the service does well: What has improved since the last inspection? Relationships between residents, staff and the new manager have improved, residents and staff have a better understanding of the reasons for changes that have been made in the home. Residents and staff confirm that they are able to raise and discuss issues with the manager and that he is contactable when not in the home. Some work is still required on care planning and risk assessment however improvements have been made and residents and staff are now much more involved in the process. Residents are being asked about their hopes and dreams and meetings are planned to look at how they can be achieved. This has also given staff a better understanding of the individuals and their needs. Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 6 Records of healthcare appointments are accessible and demonstrate that appropriate healthcare services are being accessed. Arrangements for leisure activities and access to the community are clearer and information about individual preferences is being gathered as part of the care planning process. Staff training is being provided in accordance with the needs of residents. 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. Elstow House DS0000063135.V261870.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 Elstow House DS0000063135.V261870.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): This section of the standards was not assessed during this inspection. This section of the standards was not assessed during this inspection. EVIDENCE: This section of the standards was not assessed during this inspection. This section of the standards was not reviewed during this inspection. Standard 2 the key standard to be inspected during a twelve month period has not been reviewed as it relates to the assessment of prospective residents. No new residents have been admitted under the current ownership and there are no vacancies at the present time. However interview with the registered manager prior to registration confirm that the needs of any prospective resident will be assessed prior to admission. Elstow House DS0000063135.V261870.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, More support for resident’s individual choices and aspirations is being provided through their involvement in the care planning and risk assessment processes. EVIDENCE: Discussion with staff, residents and a sample check of residents care records confirm that staff and residents have been fully involved in developing individual care plans and risk assessments since the last inspection. The process has not been fully completed however good progress has been made. Residents each have a designated member of staff who is spending time talking with residents about the support that they want and their hopes for the future. A staff member explained that when all of the information had been gathered a meeting would be held with people of the residents’ choice to develop an action plan, which would form part of the care plan. Elstow House DS0000063135.V261870.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): 12, 13, 15, 16, 17 Residents are being supported to lead a fulfilling life and individual needs and choices in relation to leisure activities and access to the community are being ascertained through the care planning process. EVIDENCE: Residents are involved in a variety of day time occupations/activities, which they talked about over breakfast. One resident was pleased that they had recently started a new job and discussion with another resident confirmed that she was receiving support to increase the number of days she worked. At the previous inspection residents and staff told the inspector that there had been a reduction in residents opportunities to access community and leisure activities. Discussion with staff, residents and the manager identified that since the last inspection discussions have taken place in the home about the activities provided which appear to be taking place in a more planned way. Individual interests and needs in relation to community access and leisure activities are being considered as part of the care planning process. Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 11 Residents told the inspector that they are due to go away for a holiday after Christmas. Residents are encouraged to maintain family links and friendships with friends and family being welcomed into the home. Residents have the opportunity to see visitors in their rooms in private if they wish. Staff were observed to be respectful of residents privacy and discussion with residents confirmed that relationships with staff are good. Residents confirmed that they are happy with the meals provided and are able to have alternatives. Elstow House DS0000063135.V261870.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 Healthcare advice, support and services are being accessed appropriately for residents. EVIDENCE: A resident confirmed that they shop for and choose their own clothes with staff support. Discussion with a staff member confirmed that personal support is tailored to the individual and that individual needs are incorporated into the care plan and agreed with the resident. Records and discussion with the manager and staff confirmed that residents’ records have been reviewed and relevant healthcare checks have been carried out or arranged. Discussion with a member of staff regarding a particular resident indicated that residents are supported in managing their healthcare needs. A sample check of the medication system confirmed that records are in place, which include details of medication held and administered. The manager carries out regular medication audits. Prescribed medication is stored in locked cabinets. Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 13 Advice was given to ensure that details of any herbal medicines/remedies taken are kept with residents’ medication records and risk assessments have been carried out for any self administration of medication. Elstow House DS0000063135.V261870.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 Residents and staff are aware of how to raise concerns and staff are aware of their responsibilities in relation to the protection of residents however unless addressed the shortfalls in the recruitment process put residents at risk. EVIDENCE: The home has a complaints procedure in place and discussion with residents confirmed that they felt able to discuss any concerns that they had with staff or the manager. A resident told the inspector that they had access to the managers mobile telephone number and was clearly happy to contact him with any concerns. The home has an adult protection policy and a copy of the Northamptonshire Adult Protection Procedures. Advice was given to develop a simple step by step guide for staff to follow in the event of an allegation of abuse. The guide should include relevant contact telephone numbers. Discussion with a staff member confirmed that they had no concerns about how residents were being treated and that if there were concerns she knew the actions to be taken to protect residents. Elstow House DS0000063135.V261870.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, 30 Residents have a clean and comfortable home to live in and appropriate action has been taken to address maintenance issues. EVIDENCE: The home is indistinguishable from any large house in the area. It is close to Northampton town centre and has easy access to the local facilities and services. Residents bedrooms are all single rooms. There is a communal lounge and dining/kitchen on the ground floor and a kitchenette and seating area on the lower ground floor available to the two residents who have bedrooms on that floor. A cleaner is employed in the home and although a full tour of the premises was not carried out the lounge and kitchen on the ground floor were clean and tidy and there were no offensive odours in the home. Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 16 The manager confirmed that since taking on ownership a review of the premises has been carried out and any health and safety issues have been addressed and are reviewed on a regular basis. Elstow House DS0000063135.V261870.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, 34, 35, 36 Procedures for the recruitment of staff do not provide adequate protection to people living in the home. EVIDENCE: A review of staff training has been carried out and staff training needs identified. The registered manager confirmed that staff are being supported to undertake relevant training which includes National Vocational Qualification training relevant to staff working with people with a learning disability. A record of induction was reviewed on a new member of staff’s file. The record was in a tick list format and appeared to have been completed all on the same day, which would require new staff to absorb and retain a large amount of information. The registered manager advised that he also has some induction books which enable staff understanding to be checked however these had not been used due to staff having the opportunity to attend an external induction training day. Following discussion the registered manager agreed to consider using the booklets for all staff to enable understanding and competence to be measured. The registered manager advised that staffing levels have been reviewed in relation to residents’ needs and additional staff provided at weekends. Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 18 A sample check of the staff recruitment process identified that although copies of criminal record bureau clearances had been obtained in the case of three staff these had been taken up by the previous employer and therefore did not provide current information. No checks had been made against the protection of vulnerable adults register. Following discussion with the registered manager about the potential risks to residents he agreed to review staff rotas to ensure that staff without the necessary checks are not working unsupervised with residents and will provide The Commission for Social Care Inspection with written confirmation of how residents will be protected. Staff files identify that the registered manager carries out formal one to one supervision sessions with staff and that staff meetings are held. Elstow House DS0000063135.V261870.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, 38, 39, 42 The manager is aware of his responsibilities in relation to the health, safety and welfare of the people living in the home. EVIDENCE: There is a registered manager in post who is suitably qualified and experienced. The shortfalls in the recruitment process identified in the pervious section are of concern however the manager agreed to ensure that immediate action was taken to ensure that residents were protected until up to date clearances for staff had been obtained. Elstow House is an established home with the majority of residents having lived in the home for many years. At the time of the last unannounced inspection residents and staff were finding the change of ownership and manager with a different approach quite difficult. Residents and staff spoken to during this inspection confirmed that the home is now much more settled and that there is a better understanding of the reasons for some of the Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 20 changes. Staff and residents confirmed that they are happy to discuss any concerns with the registered manager. The registered manager advised that there is a quality assurance process in place, which he is beginning to work through. The registered manager is very aware of his responsibilities in relation to health and safety and he has implemented a system for carrying out regular safety checks in the home. At the time of the inspection a copy of the fire evacuation procedure could not be located. Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 21 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 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elstow House Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X 2 X DS0000063135.V261870.R01.S.doc Version 5.0 Page 22 No 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 34 Regulation 13 (6), 19 (1) (b) Requirement Criminal record bureau checks must be carried out and satisfactory clearances received prior to staff working in the home. (Agreement has been reached that 3 current staff will not work unsupervised until clearances have been obtained) A fire evacuation procedure, which is clearly understood, by residents and staff must be easily accessible at all times. Timescale for action 31/10/05 2 42 13 (4) (c) 11/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Elstow House DS0000063135.V261870.R01.S.doc Version 5.0 Page 24 - 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. 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