Inspection on 11/10/06 for Shrub End Lodge

This inspection was carried out on 11th October 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 9 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 01/03/06

Shrub End Lodge 05/10/05

Shrub End Lodge 24/09/04

Shrub End Lodge 18/05/04

Similar services:

Grangewood

Upaya Ananda

15 Bramble Close

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

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 Ray Burwood Draft Unannounced Inspection 11th October 2006 09:00 Shrub End Lodge DS0000017930.V315534.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 Shrub End Lodge DS0000017930.V315534.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. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 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.V315534.R01.S.doc Version 5.2 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 14th July 2006 Date of last inspection Brief Description of the Service: Shrub End Lodge provides a service for adults with a learning disability, some of whom also have a physical disability. The home provides an ordinary living’ environment for the six adults who are accommodated in single rooms. 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. Parking facilities are provided at the front premises. The current weekly scale of charges per individual range from £500:00 to £800:00, and includes the provision of food and personal care. Service users are financially responsible for additional services such as hairdressing charges, newspapers and magazines, chiropody services and personal toiletry items. Information relating to the service provided is contained in the home’s Statement of Purpose and Service User Guide. Both are available on request to the home. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 11th October 2006 with the assistance one of the Providers, the Registered Manager, residents and staff, my thanks to them all. The site inspection visit was conducted between the hours of 10:00am and 4:00pm. The inspection involved a tour of the premises, looking at records, documents, and talking to service users and staff. Feedback and interviews with service users were positive about the standard of care and support given by staff. Service users said they were well supported in attending their various daytime activities. A total of 31 standards were inspected with seventeen of the standards being met. The remainder of the standards were partially met. At the end of the site visit, the findings were discussed with the Acting Manager and service Provider with advice and guidance offered. What the service does well: Service users are supported to use public transport in attending various colleges and day centres. The home’s staff accompanies those not able to use public transport. Service users spoken with were pleased to be involved in work and activities they have chosen to participate in. Service users who are less able are supported both within the home and by external Community Workers in accessing activities on an individual basis. Staff observed during the course of the inspection was seen to interact with service users positively. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Maintenance, health and safety issues highlighted during the site inspection, and reported under the specific headings in this report must be dealt with when a fault has been reported so that the home is a comfortable, safe, and a hygienic environment for service users to live in and staff to work in. Records required by regulation to be forwarded to the Commission known as Regulation 37 reports, or reports made available in the home known as Regulation 26 visits/reports undertaken by the Provider, must improve in order to protect service users and provide information to the Registered Manager of areas requiring attention. A programme of staff training should include appropriate training to the work they are involved in. Service users living in the home should be consulted where possible about their involvement in the running of the home, and are given more choices in promoting their independence and responsibilities. An assessment of service users’ dependency levels should be calculated using the guidelines recommended by the Department of Health to ensure that adequate numbers of staff are on duty at times they are required. Staff rotas should be further developed to include all staff and the hours they work. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s pre-assessment policies and procedures ensure that the needs of new service users are assessed by the home before offering a place. EVIDENCE: Shrub End Lodge has not admitted a service user for some years and relied on a summary of the single Care Management (health and social services) assessments in order to generate a plan of care. A requirement was issued at the home’s last inspection visit relating to assessment documentation not being in place. The home’s assessment policy and procedures have been subsequently updated and an assessment document developed should the home have a vacancy and a referral is received. Service users contracts of residency have been further developed to cover all of the areas specified under National Minimum Standard 5 and some work completed to make the document user-friendly. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear consistent care planning system in place that has been improved to enable service users to contribute to the process. Service users are able to take risks and are supported through appropriate risk assessments to promote their independence and lifestyle. EVIDENCE: Service users’ care plans examined contained sufficient information for staff to carry out the healthcare and social needs of service users living in the home. Due to the ability of some service users, their participation in the care planning process was limited, however, the further development of information documents was ongoing and some pictorial signs are now included to help assist service users in the process. It was noted that service users currently Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 11 without a social worker have not had their care plan reviewed as required under Regulation 15 (2) of the Care Homes Regulations 2001. Risk assessments associated with service users independence and daily living arrangements are in place and review dates set. Risk assessments seen on the day of the site visit identified the risks and actions to be followed by staff to minimise risk. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The dietary needs of service users are generally well met but they are not involved in process fully. Consultation with service users regarding the purchasing and budgeting of food items should be considered and encouraged as part of their independence and daily living. Links with the community are good, they support and enrich service users’ social and educational opportunities. EVIDENCE: The registered manager outlined the daily programme of service users involved in educational and recreational activities within the community. Two-service user’s, who have more complex needs and require a one to one support arrangement, have a Community Support Worker providing three Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 13 individual sessions of three hours per week. Both service users have their own motor vehicles that were purchased through the Motorbility scheme; one of the service users’ mobility has worsened since being assessed through the scheme and now requires a wheelchair. His vehicle does not allow him to take his wheelchair, therefore his needs should be re-assessed for a vehicle that can accommodate a wheelchair. Both service users access facilities that are provided at a local social centre in the community one day per week. The remainder of the service users with the exception of one, who works Monday to Friday in the town, attend local day care and college placements. Courses accessed include cooking, computer studies, employment coaching, gardening, social skills training and reading and writing. Additional community based activities were accessed by service users through the use of public houses, shopping, cinema visits and attending a drama club. One service user who was resident at the time of the site visit was observed to be involved in some housekeeping tasks before going to college. When asked if this was a regular occurrence he said yes, he enjoyed the work. Staff spoken with commented on the fact that the home did not have sufficient games and books available for service users to use during the evenings and weekends. One service user said they only wanted to put their feet up after tea but would probably use items if they were in the home. The home continues to have an open door policy regarding friends and relatives visiting and support service users who have personal relationships. Staff observed on the day of the site inspection, were seen to be respectful to the needs of service users. Staff spoken with said they manage food ordering in the home after identifying what week they were on of the three-week menu operated by the home. The owner’s wife who takes responsibility for the food budget then purchases the food listed. There was no evidence to suggest that service users were involved in this process. Staff spoken with said that fruit and vegetables purchased did not last long before they were unsuitable to be eaten or cooked. Records relating to food consumed by service user’s was in place together with their preferences about how their food is prepared. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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 health needs of service users are met with evidence of multi disciplinary working taking place. The medication systems and process in the home is well managed promoting good health. EVIDENCE: Care plans sampled and examined indicated that service users’ healthcare needs were documented and records were generally up to date. During the site inspection it was observed that the three service users in the home were supported in a sensitive manner by care staff. Staff spoke to one gentleman, who remained in bed due to not feeling well, about having his General Practitioner undertake a home visit. This he agreed to and care staff continued to monitor his condition. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 15 Specialist services had been provided for two gentlemen who had been reassessed regarding their mobility and personal handling, following concerns about suitable equipment being in place. As previously reported under National Minimum Standard 6, not all of the service users have a Social Worker consequently significant professionals are not always involved in the reviewing process. Service users are supported in accessing NHS healthcare facilities in the locality with records in place to support visits to or by a dentist, optician and a chiropodist. The home’s medication system was examined and found to be correct, Records in relation to the administration of medication were in place and up to date. Since the home’s last inspection the ordering and disposal of prescribed medicines had been improved with control measures in place to ensure that there wasn’t surplus amounts of medicines kept in the home. None of the service users were self-administering their own prescribed medication. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Staff have the knowledge and understanding of Adult Protection issues that protects service users from possible harm or abuse. EVIDENCE: The home’s complaints procedures included the required information for individuals to make a complaint if they wished. The complaints document had been revised to include some pictorial signs to help service users recognise the procedures and individuals they could associate with if they wished to complain. At the time of the site inspection the home or the Commission for Social Care Inspection had received no complaints. Since the home’s last inspection visit the Adult Protection Policy, including Whistle Blowing and procedures had been updated to include the forms of abuse that may present, and contact details of other relevant agencies who must be contacted following a concern. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 17 The home’s financial policies and practices regarding service users monies were seen to be correct and individual service users’ bank account records available and accessible to them via the Registered Manager. Most of the service users spoken with were able to manage their financial arrangements with the home in terms of fees with some support from staff. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The overall quality of the furnishings and fittings is poor and potentially dangerous placing service users, staff and visitors of injury or harm. The standard of the décor within this home is generally good but there is little evidence of improvement through maintenance or future planning. EVIDENCE: A tour of the premises was undertaken at the beginning of the site visit and the following areas were inspected: • • Premises/layout. Service users’ bedrooms. DS0000017930.V315534.R01.S.doc Version 5.2 Page 19 Shrub End Lodge • • • • Bathroom and Shower facilities. Laundry Room. Communal areas. Gardens and outside facilities. The premises and layout allowed service users access to local amenities, local transport and relevant support services, to suit their personal and lifestyle needs. Sufficient and suitable lighting was restricted in the main hallway by the lack of bulbs that were working, and those that were, not being of a voltage to ensure the area was sufficiently illuminated. The home had a maintenance request book but not a planned maintenance and renewal programme for the fabric and decoration of the premises. Service users’ bedrooms were generally well maintained, suitable to meet individual lifestyles, and contained personal items such as audio equipment, photographs and personal furniture. However, none of the bedrooms inspected were lockable. Toilet and bathroom facilities were found to be appropriate to the numbers of service users living in the home. Hoisting equipment is in place for those service users who had been assessed to need assistance when bathing. The home’s one bath and shower was not found to have the hot water outlets safely regulated (see standard 42) The Registered Manager said the bath had been fitted with a pre-set valve but it did not appear to be working efficiently. Temperature checks carried out on hot water outlets throughout the site inspection indicated that there was insufficient hot water available during the day. Staff spoken with said that a secondary heating facility had to be switched on to ensure that there was enough hot water for bathing throughout the day and evening, but this took some time before hot water was available. During the time the heating boiler was operational there was loud noises coming from the loft area. When approached about the noise, staff said that there is always a noise when it is on. The manager was advised to have the system checked over. Radiators in most locations were not of the low temperature surface type and should be covered or a risk assessment completed to ensure the safety of service users. The toilet in the bathroom had a leak at the base of it and had been reported through the normal procedures some time ago, the fault remained as requiring attention at the time of the site inspection. The bathroom did not have an alarm pull cord in place should an emergency situation occur. Laundry facilities and equipment were domestic in style and included appropriate temperatures to thoroughly clean linen and control the risk of Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 20 infection. It was noted during discussions with staff that there wasn’t a suitable sluicing facility for service users who were incontinent. The sink in the Laundry Room was used to sluice items and appeared to be inappropriate. Communal areas included a large lounge with a dining area and an additional dining area in the kitchen. During the inspection it was noted that a wall light in the lounge was covered over with a hat, when the hat was removed it was found that the wall light fitting was hanging off the wall. When asked if this was isolated the reply was yes, it wasn’t live. The Registered Manager was advised to have it checked out and made safe. Outdoor facilities included a small patio area that was unsuitable for service users, particularly wheelchair users, due to paving slabs being uneven. The outside light did not work due to lack of maintenance. The proprietor pointed out that a start had been made to relay the slabs and make the area safe. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training should be further progressed to provide staff with the specialised knowledge they require when providing care and support for people with Learning Disabilities. Adequate staffing levels ensure that service users health and social needs are generally met. However, service users’ dependency levels are not being assessed using the guidance available. The home’s recruitment process is robust and ensures the safety and protection of service users. EVIDENCE: The home employs six care support workers, three of who have a National Vocational Qualification (NVQ) Level 2, or above. Links between NVQ and the Learning Disability Awards Framework (LDAF) training should be considered for staff that work with people who have Learning Disabilities. The home’s induction process has been updated to include Skills for Care requirements. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 22 Staffing levels are maintained through two staff being on duty morning and evening, with extra support available to cover appointments and college attendance. Rotas examined provided the evidence that shifts were covered but did not include floating staff and Community Workers, or specific hours they work. The Registered Manager was advised that rotas should include all the names of staff working in the home and hours worked. Service users dependency levels had not been assessed using the Department of Health guidelines contained in the Residential Forum. Staff files were sampled, inspected and found to contain the required information and checks before they started working in the home. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home satisfactory overall but records are not well managed. This practice could potentially place service users at risk. The systems for service user consultation are good with a variety of evidence that indicates that service users’ views are both sought and acted upon. EVIDENCE: The Registered Manager of the home has the experience and skills required to work effectively in the care sector, and holds the Advanced Management in Care qualification that the Commission for Social Car Inspection (CSCI) regards as acceptable in providing evidence of transferable knowledge and skills to the Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 24 management work being undertaken. The Registered Manager was advised to seek judgement on her qualification with an NVQ Advisor. The Registered Manager is currently working three twelve-hour days per week and covers some weekend working. Her hours are divided between working with service users and management duties. The Registered Manager was advised to ensure that there were sufficient management hours to ensure that the home was run efficiently. Service users and staff spoken with were complimentary about the way the home was managed. Further work had been completed regarding the home’s quality assurance system by developing a user-friendly document for service users to complete and an action plan showing the responses from the surveys and questionnaires received. One of the issues raised by service users (females) and responded to, is improved hairdressing arrangements now in place. No feedback had been received from professionals involved with the home. The Registered Manager said a full report of findings would be available by December 2006. Discussions with the Registered Manager regarding records drew attention to Regulation 37 and 26 reports that had not been received by the Commission. The Manager was advised that records specified under Schedule 3 (j) of the Care Homes Regulations should be forwarded to the Commission. Visits by the Registered Provider (Regulation 26) and reports associated with those visits must be made available to the Registered Manager on a monthly basis and to the Commission on request. The home’s safe working practices were sampled and observed through the examination of records together with a tour of the premises. Hot water outlets were tested but a true record was not possible due to the lack of hot water. Discussions with staff indicated that the pre-set valve fitted to the home’s bath was not effective in mixing the flow correctly. Maintenance and associated records including dates of work/checks carried out were submitted by the home through the Pre-Inspection Questionnaire that was received in July 2006. The home does not currently have an effective business plan that includes financial planning, budget monitoring and financial control within the home. The home does not carry any petty cash, staff spoken with felt that they do at times need to have access to petty cash for activities and emergency purchases. Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 25 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 3 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 2 25 3 26 2 27 3 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 2 2 2 Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 26 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 YA24 Regulation 23 (2) (o)(b) Requirement The registered person must ensure that all areas accessed by individuals are safe. This relates specifically to the patio area to the rear of the premises. Also, the home has a planned maintenance and renewal programme for the fabric and decoration of the home. The registered person must ensure that the home’s call system is maintained and includes this facility in all areas accessed by service users. The registered person must ensure that maintenance work required to the home’s bathroom toilet is carried out to prevent the risk of infection. The registered person must ensure that sluicing facilities are made available if necessary, following consultation with the local Environmental Health Officer. Timescale for action 31/12/06 2. YA29 23 (2) (n) 31/12/06 3. YA30 13 (3) 31/12/06 4. YA30 13 (3) 31/12/06 Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 27 5. YA35 18 (1)(c) 6. YA39 24 7. YA41 17 (2) Schedule 4 (5)(12) 8. YA42 23 (2) (p) 9. YA43 25 The registered person must ensure that all staff receives the necessary training appropriate to the work that they are to perform. This relates the Learning Disability Award Framework (LDAF) accredited training for people who work specifically with people who have a Learning Disability. The registered person must ensure that a quality assurance process is further developed for the home, and a report of the findings made available to the Commission. (Previous timescale of 30/06/06 not met). The registered person must ensure that records required by Regulation and defined in Schedule 4, including Regulation 26 reports and Regulation 37 reports are made available to the Commission. The registered person must ensure the safety of service users, staff and visitors. This relates to suitable lighting in all parts of the home, radiators covered or risk assessed, and checks carried out by a qualified person who is CORGI registered, on the hot water boiler system. Also, checks must be carried out on pre-set valves fitted to hot water outlets, particularly the home’s bath. The registered person must ensure that a business plan for the service is available to the Commission for Social Care Inspection and which is reviewed on an annual basis. (Previous timescale of 30/06/06 not met). 31/01/07 31/12/06 31/12/06 31/12/06 31/01/07 Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 28 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 Refer to Standard YA17 Good Practice Recommendations The registered person should consult with service users and support their involvement in the planning and purchase of food items. The registered person should ensure that service users’ bedrooms are lockable and an override device is in place within a risk assessment framework. The registered person should make available bedroom keys to those service users deemed responsible to use them within a risk assessment framework. The registered person should determine staff numbers using the Department of Health recommended guidelines contained in the Residential Forum, and ensure that all people working in the home are named on the rota sheets and the hours they are working. It is recommended that the registered manager review their status in respect of their management and care qualifications through discussions with their NVQ provider. 2 YA26 3 YA26 4 YA33 5 YA37 Shrub End Lodge DS0000017930.V315534.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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