Inspection on 01/03/06 for Shrub End Lodge

This inspection was carried out on 1st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shrub End Lodge 18/09/08

Shrub End Lodge 08/05/07

Shrub End Lodge 11/10/06

Shrub End Lodge 05/10/05

Shrub End Lodge 24/09/04

Shrub End Lodge 18/05/04

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Grangewood

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Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Shrub End Lodge 119 Shrub End Road Colchester Essex CO3 4RB Lead Inspector Neal Cranmer Unannounced Inspection 1st March 2006 09:30 Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 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 Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 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. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shrub End Lodge Address 119 Shrub End Road Colchester Essex CO3 4RB 01206 575996 01206 548579 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 M Gulabkhan Mrs Susan Steele Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home accommodates 6 people with learning disabilities who may also have physical disabilities. The registered manager must review the appropriateness of their qualifications in line with the Care Homes Regulations and National Minimum Standards and provide evidence to the CSCI within three months of registration 5th October 2005 Date of last inspection Brief Description of the Service: Shrub End Lodge provides a service to adults with a learning disability, many of whom also have a physical disability. The home provides an ‘ordinary living’ environment for the six adults accommodated. The bungalow is located within a residential area of Colchester, and the property is in keeping with other dwellings in the locality. The service does not purport to provide a service for adults who have complex needs. Health care support services are those available via community access. The home does not provide nursing or specialist care. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over one day on February 2006, lasting 5.5 hours. The inspection process included discussion with one service user, the acting manager, registered provider and one member of staff. Tour of the premises included observation of communal living areas, bathroom and toilet facilities, as well as the garden area. During the course of the inspection a range of documentary evidence was sampled. Twenty-three of the forty-three standards were inspected, of these thirteen were met, five were minor shortfalls, with the remainder being major shortfalls. What the service does well: What has improved since the last inspection? Since the previous inspection the home’s Service Users Guide has been developed further and now complies with regulatory requirements. Risk assessments have undergone further development and are now much more informative documents which detail the nature of the risk and actions which staff should follow. The home has been proactive in obtaining the views of service users/and or their next of kin in the event of a service user’s demise; records seen evidenced that wishes are now being recorded. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 6 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. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 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 Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 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): 1, 2 and 5. Prospective service users are provided with the necessary information to enable them to make an informed choice about the home’s ability to meet their needs. The home does not have a pre-admission assessment by which to assess the home’s ability to meet the needs of service users referred. Further development is required to ensure that service users’ contracts of residency are written in a format that is specific to the individual, as opposed to being a generic document, and in a format that is appropriate to the needs of the service users. EVIDENCE: The Service Users Guide was sampled. This was presented in a pictorial format and included the following information: • • • • • A summary of the purpose of the home The number of places provided The relevant professional qualifications of the provider and registered manager Fees charged Brief description of the accommodation provided Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 9 The guide was presented in a very user-friendly format and the registered manager spoke of their intention to further enhance the guide. The home has not had any new admissions for a number of years. However, discussion with the registered manager indicated that the home does not have a pre-admission assessment to use for assessing the home’s ability to meet the needs of future service users. The registered manager was referred to National Minimum Standard 2 for further guidance. Service users’ contracts of residency were sampled. Although these have been improved significantly, further development continues to be required to ensure it is individualised to each respective service user and covers all the areas specified under National Minimum Standard 5. The contract also needs to be made available in a format that is user-friendly. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 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 the following standard(s): 7 and 9. The needs of the service users are complex so their abilities to make choices/decisions about their everyday lives are limited, although the home is looking at ways to enable service users more. The home’s risk assessment process has been much improved; assessments were seen to be written in a manner which was aimed at developing independence as much as possible. EVIDENCE: The needs of the service users are complex and, as such, their abilities to make decisions about their everyday lives are limited. However, discussion with the registered manager indicated that information documents are being developed in service user friendly formats. Service users are not able to manage their own financial affairs; the registered provider is appointee for service users’ benefits. Money held in the home on behalf of service users was checked, as were the records, and were found to be in order. All service users have their own bank accounts. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 11 At the previous inspection the need was identified for risk assessments pertaining to service users to be further developed. Assessments sampled on the day of the inspection were seen to be much better detailed in terms of identifying the risks and actions to be followed by staff to minimise the risk. All assessments seen had review dates set. The home has a procedure in place to be followed in respect of a person going missing; this included a recording sheet which included: • • • • A description of the service user Distinguishing features Current medication Record of visible marks and scars Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16 and 17. Service users are supported to take part in activities that are age and peer appropriate. Evidence was presented that service users are involved in the local community in a number of ways. Service users are supported to maintain links with family and friends, and to develop friendships outside of this circle. Service users’ rights are respected. The home’s routines and rules were not seen to impede independence. Service users had unrestricted access to all areas of the home. The evidence provided on the day of the inspection indicated that service users are provided with a healthy diet. Meals were provided so as to facilitate activities. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 13 EVIDENCE: Discussion with the registered manager evidenced that one service user is in a supported working job for which they receive payment. A second service user is involved in some voluntary occupation. One of the two above mentioned service users also attends a day centre and college once a week. Another also attends college twice weekly where they partake in cookery and art classes. Further discussion with the registered manager indicated that two of the service users residing at the home are active members of the local church, attending twice weekly. They also attend church meetings and both took part in the Christmas nativity play. Both have also been involved in charity work through the church. Members of the church group regularly visit the home and through this process the home maintains an active presence in the local community. The home further involves service users in the community through accessing the following community based activities: • • • • • Using local public houses Shopping for food locally Going out for meals Using the local cinema Attending a drama club The home has an open door policy on the receiving of visitors, and the manager spoke of relatives always being welcome at the home. Service users have opportunities to make links with others who do not have their disability. The manager spoke of one service user who is maintaining a personal relationship with a person of their choosing and the support the service user is being given to support this ongoing relationship, both emotionally and from an educational perspective. Service users have unrestricted access to all areas of the home and garden, dependent upon their individual needs. The manager spoke of the policy at the home being that all staff knock before entering service users’ rooms. Service users were heard to be referred to by their Christian names and in a respectful manner. Staff were seen and heard to interact with service users and not exclusively with each other. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 14 The home operates a three-weekly rotational menu plan which evidenced that the menus provided were varied and nutritious. Meals were seen to be provided three times daily, at least one of which was seen to be cooked. Meals were provided flexibly to accommodate service users’ accessing activities. The home maintains a record of food consumed by service users and each service user’s file contained a brief write up of how the service user liked their food to be prepared. Food stocks sampled on the day of the inspection were seen to be adequate and there was evidence of fresh fruit being available to service users. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 15 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): 19, 20 and 21. Service users’ physical and emotional healthcare needs were deemed to be well catered for. Service users were not able to manage their own medication. Procedures at the home were sampled and were deemed to be safe and in order. The wishes of service users and/or their next of kin were in the process of being collated and recorded in the event of a service user’s demise. EVIDENCE: All service users are registered with a local general practitioner, dentist and optician. Care plans sampled evidenced that healthcare records are generally well maintained. Evidence was seen of input from the following healthcare professionals: • • • • • General Practitioner Consultant Psychiatrists Nurse practitioners District Nurses Hospital Appointments DS0000017930.V285345.R01.S.doc Version 5.1 Page 16 Shrub End Lodge Discussion with the registered manager indicted that medication records are now being monitored on a daily basis. Evidence was presented that the registered manager has been in the process, and remains so, of recording the wishes of service users and/or their relatives in the event of a service user’s demise. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 17 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. The home’s complaint procedure requires further development in terms of being available in a format that is appropriate to the needs of the service users. The home’s adult protection procedure requires some further development to fully comply with requirements. EVIDENCE: The home has a complaints policy/procedure which was seen to include the timescale within which any complaint received would be responded to. The policy /procedure was also seen to make reference to the fact that a complainant may refer their complaint to the CSCI at any stage of the complaint process. At the time of the inspection no complaints had been received in respect of the home by either the CSCI or the home. Although the complaints procedure contained all the relevant information, it needs to be made available in a format that is more user-friendly and appropriate to the needs of the service users. The registered manager is in the process of reviewing the home adult protection procedure. It was recommended that the manager ensures the following areas be included: • • • Forms of abuse that may take place Examples of how this abuse may present Contact details of other relevant agencies Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 18 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. Service users are supported in an environment that is homely, comfortable and generally safe. EVIDENCE: The premises were deemed to be fit for their stated purpose, being safe and generally well maintained. The home was comfortable, bright and cheerful and was free from any foul or unpleasant odours The home is situated close to the centre of Colchester and is in very close proximity to a bus stop. The premises mixes in well with the local community; being a bungalow it is accessible to all service users. Furnishings and fittings were seen to be of a generally good quality and were domestic in nature. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 19 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 and 35. Service users are supported by a team of staff who know them well and who are qualified at NVQ Level 2 in care. The home needs to further develop its training for the staff team and ensure that a comprehensive induction for all new starters is in place which meets with Skills for Care requirements. EVIDENCE: The home employs five care staff, of whom two are qualified at NVQ Level 2, with a further one being in the process of completing the award. The home does not employ any trainees or persons under the age of eighteen. The registered manager has commenced collating training records for all staff, which evidenced that food hygiene and appointed persons first aid training has taken place since the previous inspection: Staff are supported and encouraged to discuss their training needs/ requirements during supervision. Although the home has in place a basic induction process, further significant development is required to meet with the requirements of National Minimum Standard 35 and Skills for Care requirements. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 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 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, 41, 42 and 43. The registered manager needs to ensure that they are qualified to NVQ Level 4 in both management and care. The registered manager needs to further develop the process of quality assurance at the home, ensuring that the views of service users and other interested stakeholders are taken into account. The registered manager must ensure that the records required under regulation are held in the home. The home’s safe working practices appeared to be in order; certificates of safety seen were all in order. The registered person needs to develop a business plan for the service that is open to the CSCI for inspection and is reviewed on an annual basis. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 21 EVIDENCE: The registered manager has a number of years’ experience of working in the care sector, although they are not qualified at NVQ Level 4 in management. However, they do hold an Advanced Management in Care and they have consulted with an NVQ provider as to whether this is equivalent. Some initial work has been undertaken on developing a process by which to measure the quality of the home’s service provision through the use of questionnaires. However, further development is required to extend this to a wider range of stakeholders. The registered manager will then need to give further consideration as to how to collate this information into a format that can be used as a means to developing and further improving the home. A number of records required by regulation continue to either not yet be available or require further development to meet with regulatory requirements, which include assessments of need and a quality assurance process. The home’s safe working practices were sampled through the viewing of the following safety certificates: • • • Electrical installation Portable Appliance test Fire extinguisher maintenance The home’s gas services certificate was also seen. A fire safety inspection defect notice regarding the lounge door was seen. This was reported has having been rectified and a letter was provided evidencing that the fire officer was revisiting the home on 2nd March 2006 to confirm that the work identified had been undertaken and was in compliance. The home does not currently have a business plan. Discussion took place around the need to develop one for the service. The registered manager was referred to National Minimum Standard 43 for further guidance. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 1 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 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 X 3 3 3 2 X 1 X 2 3 1 Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 23 Yes 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 YA2 Regulation 14 Requirement The registered person must not admit to the home any service user whose needs they have not assessed as being able to meet. This relates specifically to the need for a pre-admission assessment to be developed. The registered person must ensure that a contract of residency is made available to service users in a format that is user friendly. The previous timescale of 31/12/05 was not met. The registered person must ensure that the complaints procedure is appropriate to the needs of the service users. The registered person must ensure that all staff receive the necessary training appropriate to the work that they are to perform. The registered person must ensure that a quality assurance process is developed for the home that is based upon consultation with service users. The previous timescale of 30/03/06 was not met. DS0000017930.V285345.R01.S.doc Timescale for action 30/06/06 2. YA5 5 30/06/06 3. YA22 22 (2) 30/06/06 4. YA35 18 (i) 30/06/06 5. YA39 24 30/06/06 Shrub End Lodge Version 5.1 Page 24 6. YA41 17 The registered person must ensure that the records specified under Schedule 3 of the Care Homes Regulations are maintained at the home in respect of service users. The previous timescale of 31/12/05 was not met. The registered person must ensure that a business plan for the service is available that is open to the CSCI for inspection, and which is reviewed on an annual basis. 30/06/06 7. YA43 25 30/06/06 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 YA23 YA37 Good Practice Recommendations It is recommended that the homes Adult Protection Procedure be reviewed. It is recommended that the registered manager review their status in respect of their management and care qualifications through discussions with their NVQ provider. Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Shrub End Lodge DS0000017930.V285345.R01.S.doc Version 5.1 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!