Inspection on 16/08/06 for Elstow Lodge

This inspection was carried out on 16th August 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elstow Lodge 13/02/06

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

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

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 16th August 2006 01:45 Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 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.V307861.R01.S.doc Version 5.2 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.V307861.R01.S.doc Version 5.2 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.V307861.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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. The minimum fee was £361/- and the maximum fee was £600/-. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out on 16/08/06 over 3 ½ hours by pursotamraj hirekar. The method of inspection included review of outstanding recommendations, study of care plans, risk assessments, staffs’ files. Discussion with the service users’, staffs on duty and the manager, partial tour of the premises and observations. The manager had coordinated the entire inspection. 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.V307861.R01.S.doc Version 5.2 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.V307861.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide enabled potential service users to make informed decisions. EVIDENCE: There has been no new admission, since the previous inspection. The statement of purpose and service user guide enabled potential service users to make informed decisions. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had to review the risk assessments and update the careplans to incorporate the changing needs and aspirations of the service users’. EVIDENCE: On a random basis, three service users’ cases were tracked on this inspection and their details are as follows: Service user – 1 the latest risk assessment was carried out on the 01/06/01. The current care plan had detailed information about medical appointment, wishes in the event of death, record of visits by doctors, weight chart, washing, bathing, wash hair, encourage to use deodorant, soap and daily record was maintained regularly. The service user was interested to move to move to Luton and a professional meeting was organised by the Luton social services on the 08/08/05 and decided that the service user must stay at the current home. These and further development were not updated into the care plan. Service user – 2 annual reviews was conducted by the social services on 8/9/5 the service user, manager and senior practitioners from the social services participated. Service users’ care plan was dated 2004. The home needs to prepare a service user care plan taking into account the changing needs. Record of bath, weight and daily dairy Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 9 of the service user was maintained. Service user – 3 Annual reviews was carried out on 05/01/06, service user, manager, day care centre personnel and the reviewing officer participated. The review primarily focused on the day care activities of the service user based with in the special unit division of the day care centre. The manager has agreed to complete risk assessments and care plan reviews and incorporate the changing needs and aspirations of all the service users’ in consultations with the social services, service users’ family/relatives/advocates and prepare a comprehensive care plan for all the service users’ before 15/10/06. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 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, and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had consultations with all service users’ and developed activites that meet the individual service users’ needs and aspirations to achieve quality of life goals. EVIDENCE: Service user – 1 goes to day care centre 5 days a week. Keeps in regular contact with family every Sunday, visits once every 6 weeks and sometimes-on bank holiday as well. Service user –3 attends 5 days a week day care centre. Service user – 2 the care plan review carried out on 8/9/5 identified that the service user wanted to go to day care centre once a week, which the manager said later that the service user had refused to go. Although the service user does not have a regular routine of daily activities, but does once a week parttime work based employment at kid’s world, Bedford. At the time of this inspection, the service users’ had just returned from their day care centre and were relaxed for sometime. The service users’ were offered healthy diet and found to have enjoyed their meals and mealtime. The home had made arrangements for service users’ to have appropriate contacts Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 11 with their families and friends. The staffs’ engage the service users at home in various leisure time activities for their personal development. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessed personal and health care needs of the service users’ were met as per the care plan. EVIDENCE: The service users’ health care appointments, doctor’s visit, weight, bowel, bath, shower, brushing and daily record were maintained appropriately for all the service users’. Service user – 1 medication review was done on 17/2/6. Letter dated 31/01/06 stated that one service user’s Medical appointment was not honoured at dementia clinic. Later it was rescheduled. The trained staffs administer medication and the medicine was stored in a safe place. It was observed during the inspection that, the staffs and the service users’ have good working relations. . Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 13 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements with regard the complaints policy and procedures. EVIDENCE: There was no complaint received since the previous inspection. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 14 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 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home had redecorated and maintained comfortable environment for the service users’. EVIDENCE: The home was maintained clean and tidy. The home carried out redecoration and had made changes that included, new shower, down stairs bath redecorated, new sink, toilet, bath and shower, new carpets in lounge, bedroom number 3 redecorated with new carpet, new bed, new curtains, bedroom number 4 was redecorated but was erected by the service user. Hallway was in the process of redecoration and re-carpeting. New cooker was replaced in the kitchen and upstairs one toilet repainted. The home had carried out routine health and safety checks, which included; gas connection check was done on 12/04/06, emergency lighting test carried out every month and weekly alarm test was carried out regularly, fire fighting equipment annual record was maintained. Manual fire alarm, fire drills and electrical appliances checks were regular. However, water temperatures for all water points need to be recorded separately. The manager had agreed to start carrying out once a week food and fridges temperature. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 15 Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 16 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 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home had a good skill mix of staff that complemented service users’ particpation. EVIDENCE: In the previous inspection report a recommendation was made that the home should ensure to have at least one staff member available at the home all the time. In response, the manager had given her mobile phone number to the day care centre for contact and if required the manager would then contact staff member who live in close proximity for any work at the home. In response to another recommendation ‘Staffs’ supervision schedule should be streamlined and supervision meetings are recorded’. The home manager had now planned to start individual staff supervision from September 2006. Staffs’ have had statutory trainings. Random check of staffs’ files was carried out on this inspection and found that, staff – 1, had 2 references, no CRB clearance and no POVA check was done. Satff-2, 1 reference was outstanding, no CRB and POVA checks were carried out. The manager had agreed to take off the staffs without CRB and POVA from the duty rota with immediate effect and would re-employ on obtaining satisfactory statutory checks, until such time the manager had planned to do Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 17 shifts and arrange for staff. The manager had also planned to issue new job contracts for all the staffs. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home was managed well. The manager and the staffs work as a team in the interest of service users’. EVIDENCE: The manager, staffs and the service users’ have good working relation. The service users’ spoken to were happy with the service provision and the care they were receiving at the home. The manager was in the process formalising staffs’ supervision starting in September 2006 and planning a training calendar for the staffs on the basis of their training needs assessment. The manager had also agreed to review the staffs’ recruitment policy and procedure before 15/09/06. The manager was planning to carry out stakeholders, survey as part of the annual quality audit and use the findings for developing a business plan. This, the manager was hoping to complete before 15/11/6. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 19 The commission had received a fax on 18/08/06 from the manager detailing the time plan to complete the shortfalls that were found during the inspection. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 21 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 YA6 Regulation 15 (2) Requirement The home must review risk assessment, care plans and updated to reflect the changing needs and actioned. Staffs are employed in post only following completion of satisfactory statutory checks. Staffs’ employed without satisfactory completion of statutory checks are taken off from duty until satisfactory statutory checks were obtained. Timescale for action 15/10/06 2. YA34 19 18/08/06 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 YA36 YA39 Good Practice Recommendations Staffs’ supervision schedule should be streamlined and supervision meetings are recorded. The home should carry out a stakeholder feedback survey and use the results for developing an annual development plan. Elstow Lodge DS0000014899.V307861.R01.S.doc Version 5.2 Page 22 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.V307861.R01.S.doc Version 5.2 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. 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!