Inspection on 13/02/06 for Elstow Lodge

This inspection was carried out on 13th February 2006.

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 Lodge 16/08/06

Elstow Lodge 12/10/05

Elstow Lodge 01/03/05

Elstow Lodge 18/08/04

Elstow Lodge 02/02/04

Elstow Lodge 12/08/03

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Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Elstow Lodge Wilstead Road Elstow Bedfordshire MK42 9YD Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 13th February 2006 02:45 Elstow Lodge DS0000014899.V272410.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 Lodge DS0000014899.V272410.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 Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elstow Lodge Address Wilstead Road Elstow Bedfordshire MK42 9YD 01234 405021 01234 214664 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) Mr R M Sabey Mrs J Stokes Care Home 11 Category(ies) of Learning disability (11), Physical disability (1) registration, with number of places Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 2005 Brief Description of the Service: Elstow Lodge is a large detached house standing in well-maintained gardens. It is situated in the village of Elstow where there is a post office, church, and two public houses. There is a bus route to Bedford from Elstow. Some shops are located nearby, and there is ample parking at the home. The family run home is registered to provide residential accommodation for 11 adults with learning disabilities, and for 1 adult with physical disabilities. There is one bedroom on the ground floor, along with two lounges, the dining room, kitchen, and small laundry area. The remaining bedrooms, two of which are shared, are situated on the first floor. Residents are able to use the large garden, patio, and barbeque facilities provided. Most of the residents attend activities outside the home on most, or all weekdays. Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out at 2.45pm on 13/02/06 by Pursotamraj Hirekar over 2 ½ hours. The manager had coordinated the inspection. The method of inspection included study of care plans, risk assessments, personnel files, partial tour of the home, conversations with the service users and discussions with the manager. 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. Elstow Lodge DS0000014899.V272410.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 Elstow Lodge DS0000014899.V272410.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): 2 The home had made appropriate arrangements to facilitate informed choice and decision making for the potential service users. EVIDENCE: Service users have had prior information of services and facilities provided by the home to make an informed choice and decision. The needs and the aspirations of the service users were assessed prior to their admission. Elstow Lodge DS0000014899.V272410.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): 6,7,9 The care plans were comprehensive and addressed the changing needs and aspirations of the service users. EVIDENCE: The care plans were comprehensive covering various details of service users needs and the ways and means to achieve them. Three service users care plans were reviewed in December 2005 and two service users care plans review was scheduled for March 2006. The manager was of the opinion that the care plans review is just a formality when the home was in constant dialogue with the service users day in and day out. The changing needs were met immediately, without waiting for the care plans to be reviewed and then outcomes to be actioned. Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 9 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): 11,12,13,17 The home had made appropriate arrangements to meet the dietary needs and life styles of the service users. EVIDENCE: The manager and the staff have encouraged the service users to lead an independent life through various forms of stimulations and a wide range of activities. The service users were lively, full of excitement and appeared cheerful. All the service users were dressed neatly and appeared clean. The service users enjoyed the company of the manager and always looked forward to talking with the manager again and again. The manager also enjoyed the company of the service users and spends quality time with the service users. The manager, staff and service users have a good working relationship that stimulates independent thinking and living. The home had made arrangements to provide a nutritious and balanced diet for the service users. The service users, during the conversation, said they liked the food, college, meeting visitors and the staff. Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 10 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): None EVIDENCE: Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 11 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 manager was open to suggestions that were in the best interests of the service users. EVIDENCE: The manager of the day care centre telephoned the duty desk of the commission, to say that service users coming from the home when ill, and staff at the day care centre sometimes struggle to get in touch with the home to allow service users to go home. The above concern was discussed with the manager and the manager was in agreement with the concern and said that on this particular day she was away in Cambridge and returned to the home by 2.00pm. Since the home is meant to be a 24 hours service care home it was apparent that at least one staff member need to be on duty all the time. Also to attend any emergency for the service user who do not go to the college and live alone at the home. The manager had agreed to ensure the availability of at least one staff member all the time in the home. Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 12 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 The home was clean, pleasant, hygienic and comfortable for the service users. EVIDENCE: Overall the home was clean, pleasant, hygienic and very well maintained. The communal areas were spacious and well decorated. The manager had said that they have planned to decorate the lounge. Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 13 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): 33,34,36 The manager had made appropriate arrangements with regard to staff recruitment and supervision. However, the second written reference and structured staff supervision needed attention to achieve the best value of care delivery. EVIDENCE: The pre-employment checks were in order except one reference for two staff members was obtained on the phone. The manager had agreed to follow-up with the referees for a written reference and in the meantime she would minute the telephone reference. Staff supervision planning had been formulated and would commence from March 2006. Staff training needs have been assessed and staff were trained in safe handling of medicines, POVA, dementia and first aid. Staff deployment; please refer to complaints section of this report. Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 14 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The home was managed in the best interest of the service users. EVIDENCE: The home had the benefit of a committed, qualified and experienced manager to manage the affairs of the home. The manager, staff, service users and their representatives have a professional relationship that helps in achieving the assessed needs of the service users. The service users have expressed satisfaction for the services they have received and the support they receive from the staff and the manager in particular, as and when they required. Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 15 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 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 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 X 2 2 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elstow Lodge Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000014899.V272410.R01.S.doc Version 5.0 Page 16 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. Standard Regulation Requirement Timescale for action 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. 3. Refer to Standard YA33 YA36 YA34 Good Practice Recommendations The home should ensure to have at least one staff member available at the home all the time. Staffs’ supervision schedule should be streamlined and supervision meetings are recorded. The manager should follow-up and obtains second written reference from the referee of two staffs. Elstow Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Lodge DS0000014899.V272410.R01.S.doc Version 5.0 Page 18 - 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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