Inspection on 18/09/08 for Shrub End Lodge

This inspection was carried out on 18th September 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shrub End Lodge 08/05/07

Shrub End Lodge 11/10/06

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

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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 27/11/2008.

CARE HOME ADULTS 18-65 Shrub End Lodge 119 Shrub End Road Colchester Essex CO3 4RB Lead Inspector Ray Finney Unannounced Inspection 18th September 2008 09:00 Shrub End Lodge DS0000017930.V372255.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.V372255.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.V372255.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 523329 mgulabkhan@hotmail.com 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 Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Shrub End Lodge DS0000017930.V372255.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 8th May 2007 Date of last inspection Brief Description of the Service: Shrub End Lodge is a residential care home providing long stay care for six adults with learning disabilities. The bungalow is situated in a residential area of Colchester. There are local shops close by and there is easy access to public transport. There are parking facilities to the front of the property as well as unrestricted parking on some of the surrounding roads. Accommodation is in single rooms and there is a communal lounge and dining room. Both the kitchen and separate laundry/utility room are domestic in character. The home charges between £464.00 and £547.00 a week for the service they provide. This information was given to us in September 2008. Additional items not covered by the fees include toiletries and personal items. Information about the home, including the Statement of Purpose and Service User Guide, can be obtained by contacting the manager. Inspection reports are available from the home and from the CSCI website www.csci.org.uk Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as food records, staff rotas, care plans and personnel files. An Annual Quality Assurance Assessment with information about the home was completed by the manager and sent to us before the inspection. Throughout the report this document will be referred to as the AQAA. A visit to the home took place on 18th September 2008 and included a tour of the premises, discussions with some of the people living in the home, the proprietor and members of staff. Observations of how members of staff interact and communicate with people living there have also been taken into account. On the day of the inspection the atmosphere in the home was relaxed. were given every assistance from the proprietor and staff. We What the service does well: What has improved since the last inspection? There have been improvements to the environment redecoration in the communal lounge and dining areas. including some Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 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.V372255.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Through the comprehensive admission process, people choosing to live at Shrub End Lodge can be confident that their needs will be met. EVIDENCE: The manager states in the AQAA, “We have a statement of Purpose and a Service User Guide that show the services we provide and how we are going to attend to their needs on an individual basis”. Individual files examined on the day of the inspection all contained a copy of the Service User Guide. In the last year two people have moved into Shrub End Lodge from another home locally. Through discussion with the manager, he was able to demonstrate an awareness of the importance of a good assessment process. The manager states on the AQAA, “Assessment of need and aspirations of each candidate are made prior to admission” and “The person who needs our support will have an opportunity to visit and ‘test drive’ the home to see if they like it. They will be given a contract. Each person we support have a contract of residence explaining the terms and conditions of our agreement to deliver the service according to their choice”. Records examined show that the home’s assessment process, the ‘Admission Needs Assessment’, was followed for the individuals who moved in. This Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 9 included a Personal and Social History documenting the person’s background. Other areas covered in the assessment were personal care needs, healthcare, requirements for any aids and adaptations, the person’s likes and dislikes, spiritual needs, sexuality, information about benefits and finances, behavioural and mental health needs. The records also contained an assessment of the individual’s manual handling needs. Shrub End Lodge DS0000017930.V372255.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. People living in Shrub End Lodge receive good quality care, which is based on their assessed and identified needs. EVIDENCE: The manager states in the AQAA, “Each person we support has an individual care package containing information for staff to carry out their health care and social needs”. On the day of the inspection a sample of four care plans were examined. The care plans each contain an individual ‘Personal Profile’ that gives information about the person’s background and contains sufficient details about their habits and preferences. Care plans set out the identified need or problem and what the objectives or goals are for the person. Care plans are evaluated monthly. They also contain a detailed daily routine which is a guide to how the person plans their day. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 11 Individual files each contain a ‘Statement of Rights’ that sets out people’s right to privacy and to be treated with dignity and respect. A member of staff who completed a survey stated, “Staff always knock on the door before going in a service user’s room”. Care plans examined contained ‘decision making’ records. One person spoken with on the day of the inspection explained that they were in the process of choosing furnishings for their room. The manager states in the AQAA that each person living in Shrub End Lodge is, “supported to make decisions about their lives” and that people are “consulted regularly through meetings and reviews to assess their needs and their choice”. Daily records also contain evidence of what people choose to do on a daily basis. The manager states in the AQAA, “Risk assessments associated with the people that use our service, [their] independence and daily living are in place”. Records examined confirm there are risk assessments in place relating to needs that have been identified through the assessment and care planning process. The nature of the risk is identified, there is a rationale as to “Why take the Risk?” and there is a risk management strategy in place detailing ways to reduce or minimise the risk. Shrub End Lodge DS0000017930.V372255.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, 14, 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. People living in Shrub End Lodge can expect to enjoy a lifestyle that meets their wishes and interests. EVIDENCE: There is an individual planner in each person’s file that documents how people spend their time. Planners contain ample evidence that people living in the home attend courses at the local adult education centre, including cooking, gardening, arts and crafts. The manager states in the AQAA, “We work together with the people that use our service to give them opportunities for personal development” and “Monthly meeting with the people that use our service has helped us to provide a service that is appropriate to their needs”. One person spoken with on the day of the inspection said that they used to work in supported employment either doing cooking or woodwork and they really enjoyed going there every week. They had photographs in their room of Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 13 when they used to go to work and took pride in showing us them. This facility has now closed and they have recently started to do voluntary work at a local children’s nursery as well as doing courses at college. Records examined also contain evidence that people are involved in using facilities in the local community, including the library, shops and the local pub. A recent trip to Clacton Air Show was enjoyed by people living in Shrub End Lodge. The manager states in the AQAA that people, “are encouraged to live as independently as possible” and “are members of the local library, church and go to their local public house. They go to the cinema. They are listed on the local electoral roll”. A member of staff who completed a survey said, “We have many activities on offer during the week and weekend including pub visits, town, bowling, cinema. All service users have the opportunity to take part if they wish”. On the day of the inspection four of the six people living in the home people were out at planned activities. Activity planners and daily records also contain evidence of in-house activities such as games, puzzles, karaoke, bingo and watching videos that people do in the evenings. A member of staff said, “In the evenings we play games, bingo etc or work games, reading and writing. Again service users have the opportunity to not take part if they wish”. Evidence was examined in the daily records that confirms people living in Shrub End Lodge are supported to keep in touch with friends and relatives. One person’s file said the they ‘wrote letters’ and ‘had a phone call from [their relative]’. One person spoken with on the day of the inspection was looking forward to going to visit relatives for a planned holiday and said the their relative phones every week and visits once a month. A range of areas relating to people’s involvement in the day to day running of the home are covered in people’s individual care plans including ironing, using the kitchen and shopping. The manager states in the AQAA that people, “are incorporated in decision making of the home. They decide on the food they want and eat hence they enjoy their meals. They help in purchasing food and get involved in preparing the meals”. Activity planners show that people are involved in ‘stocktaking’, making shopping lists and going with staff to do the food shopping for the home. A member of staff who completed a survey stated, “All service users have the opportunity to go shopping for food at the supermarket and choose what they would like”. As people go out a lot during the day, the main meal is in the evening and they have a light lunch such as sandwiches of their choice. Two people were observed to enjoy their lunch on the day of the inspection; both had different sandwiches and desserts. One person was having fresh fruit for dessert and said they enjoy that. Both told us that they enjoy the food in the home. There Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 14 is a menu but staff said that they always ask people what they want to eat on a daily basis, so the menu is for suggestions only. Records show that a range of food is available including spaghetti bolognaise, jacket potatoes and fish and chips. The notice board in the kitchen has leaflets and guidelines about healthy eating. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 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. 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. People using the service can expect their personal and healthcare needs to be identified and provided with the support to ensure these needs are met as they would wish. EVIDENCE: Care plans examined contained sufficient detail to ensure people receive the support they need in ways that they wish. Through discussions with the proprietor he was able to demonstrate a good awareness of people’s individual needs. Throughout the day of the inspection staff were observed to treat people with respect. A relative who completed a survey stated, “All aspects of care to their clients always comes first. General care to them all is first class”. The manager states in the AQAA, “Care plans are in place to maintain records of the people that use our service in respect of their physical and emotional needs. They have a dental check up every six months and an eye test every year” and “Records for all healthcare received have been kept separately for easy reference in the future”. Information about people’s individual medical and healthcare needs were documented in the sample of records examined. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 16 There was evidence of the management of epilepsy with detailed guidelines for members of staff. Records examined contained details of a range of appointments with healthcare professionals including doctor, surgery nurse, dentist and consultant psychiatrist. There are a range of charts for recording health related information including weight and seizures. Records of preventative procedures are in individual files including dates for flu vaccine injections and women’s healthcare screening procedures. A survey completed by a relative states that what they feel the home does well is “Looking after my [relative’s] health needs, listening to [their] concerns and generally keeping [them] safe”. Members of staff also made positive comments about how people are supported with their healthcare needs. One said, “Service users have the opportunity to visit the GP, dentist and opticians when they wish and have six-monthly check ups”. The manager states in the AQAA, “Medication is administered as per the home’s policy. Check lists at the beginning of each shift are completed to make sure that all medications have been administered as prescribed”. Although no-one living in the home self medicates, one person’s individual file contains details of their prescribed medication with details of what is stored and administered by staff and other items that are stored by the individual and self-administered, such as asthma inhalers, eye drops and ointment. Medicine Administration Record (MAR) sheets were completed appropriately. A survey received from a member of staff stated, “Medication is always given on time and dispensed properly”. The storage of medication was examined and found to be inappropriate. The current storage facility is a lounge unit with a section that has been secured with a small padlock. The piece of furniture was not secured to the wall and the lockable section was not robust. The lockable section of the cupboard used for the storage of medication was small and, although people’s medicines were kept in separate containers and the cupboard was tidy, there was insufficient space to store topical preparations (such as ointments) separately from tablets and other medicines that are taken orally. The home is registered to care for six people and the small space available was inadequate for the storage of medication for this number of people. Guidelines for the handling of medicines in social care, available from the Royal Pharmaceutical Society of Great Britain, states that when medicines are stored centrally “the cupboards must be big enough, well constructed and have a good quality lock”. The current storage facility does not comply with these guidelines. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 17 Legislation states that care homes must store controlled drugs in a controlled drugs cupboard, including care homes registered for personal care. A controlled drugs cupboard is a metal cupboard of specified gauge with a specified double locking mechanism that is securely fixed with either ‘rawl’ or ‘rag’ bolts to a solid wall or a wall that has a steel plate mounted behind it. Shrub End Lodge does not have a controlled drugs cupboard. Although no controlled drugs are currently in use, should anyone living in the home be prescribed this type of medication they could not be sure that their medication would be stored safely. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 18 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. People who use the service can be confident that their concerns about how they are treated are listened to and acted upon as stated in the complaints and safeguarding procedures. EVIDENCE: As at the last inspection, Shrub End Lodge has a robust policy and procedure in place for dealing with complaints, a copy of which is made available to everyone in the home. The manager states in the AQAA, “We have a complaint procedure for people to make a complaint if they are not satisfied with the service we provide”. No formal complaints have been recorded since the last inspection. Through discussions with the manager and members of staff it is apparent that minor concerns are dealt with as and when they arise. People living in the home are given opportunities to discuss concerns both informally and during service user meetings and they are recorded in the minutes of the meeting. One person living in the home said if they had any problems they would be able to discuss them with staff. Staff spoken with on the day of the inspection understood their responsibilities around safeguarding people (previously called Protection of Vulnerable Adults or POVA). Personnel records contain evidence that all staff undergo Criminal Record Bureau (CRB) checks before commencing employment in the home and staff have received safeguarding training. The manager states in the AQAA, Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 19 “All staff have attended adult protection course so that they can recognise abuse and report it”. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can enjoy living in an environment that suits their lifestyle and which is homely, well maintained and clean. EVIDENCE: A tour of the premises confirmed that, as at the previous inspection, the communal areas and bedrooms were well-maintained. Furnishings are domestic and comfortable and people living in Shrub End Lodge benefit from the homely surroundings. The manager states in the AQAA, “We have maintained the environment to a good standard by attending to all repairs that needed doing”. People’s bedrooms are decorated individually to the taste of the person using the room. One person living in the home was pleased to show us their room and took pride in keeping it clean and tidy. There was ample evidence in people’s rooms of personal possessions such as pictures, photos, ornaments and music equipment. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 21 The manager states in the AQAA that, since the last inspection, they have, “Purchased new furniture for one person that uses our service. New carpet fitted and the room completely redecorated according to [their] wishes”. Throughout the home the standard of cleanliness is good and there are no unpleasant odours. The laundry is small but contains equipment and facilities that are appropriate for the size of the home. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 22 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 good. This judgement has been made using available evidence including a visit to this service. People living in Shrub End Lodge are cared for by a competent staff team who can meet their needs and have been employed following thorough recruitment checks to ensure people living at the home are safeguarded. EVIDENCE: The manager states in the AQAA, “All staff have got NVQ level 2 in care”. Through discussion with the proprietor it is evident that the staff team have been committed to obtaining National Vocational Qualifications (NVQ). Information provided in the AQAA indicates that all eight of the team of carers have completed an NVQ at level 2, which exceeds the minimum of 50 of carers with NVQ as recommended in the National Minimum Standards. A sample of personnel records examined contain evidence that staff have completed the award. Staff rotas examined show that there are two members of staff on during the day and one person at night. On the day of the inspection staffing levels were seen to be appropriate and people’s needs were being attended to promptly. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 23 People living in the home were complimentary about the staff team. person said, “they are very good”. One As at last inspection the home operates an appropriate recruitment process. The manager states in the AQAA, “After receiving satisfactory references, enhanced disclosures and POVA the candidate will commence work after completing a week induction of the job”. A sample of three personnel files examined contained all the documentation required by regulations, including photographs, two written references, relevant proofs of identity and a declaration that the person is fit to carry out their role. Criminal Record Bureau (CRB) enhanced disclosure checks are carried out to help safeguard people living in the home by ensuring that anyone who is prohibited from working with vulnerable people is not employed. A member of staff who completed a survey stated, “I had a one week induction course during which time I completed an induction form. I also attended an induction course about care for people with learning disability”. The staff team working at Shrub End Lodge have been established for a number of years. There is evidence in personnel records examined of a range of staff training relevant to the roles they are carrying out. This includes manual handling, drug administration, Protection of Vulnerable Adults (POVA), food hygiene, first aid and Health and Safety, which includes Control of Substances Hazardous to Health (COSHH). Training for staff is updated annually by a two day ‘six pack’ course that covers food hygiene, infection control, basic life support, safe moving and handling, POVA and health and safety/fire. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 24 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Shrub End Lodge can be confident the home is appropriately managed in their best interests. EVIDENCE: The proprietor explained that he now manages the home on a full time basis. Although the proprietor is registered with us at the Commission as the Responsible Individual for the service he is not the registered as manager. However, he has confirmed with our Regional Registration Team that there is no statutory requirement for the proprietor to be registered with us at the Commission. On the day of the inspection we discussed the home’s Quality Assurance system with the manager. Shrub End Lodge has a process in place for seeking the views of people using the service and the evidence is recorded in the Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 25 home’s Quality Assurance file. Surveys were completed by people living in the home. Records examined contain evidence of other ways in which people are consulted including minutes of meetings. Similarly staff are able to give their opinions through regular staff meetings. The manager states in the AQAA, “We make sure that the people we support are confident that their views underpin all self-monitoring and that their rights and interests are safeguarded”. Sufficient evidence was presented to confirm that the proprietor actively seeks the views of people living in the home and acts on the information that they receive. The information has been collated into a report but could be developed further to include a development plan for the home. As at the last inspection policies relating to health and safety are in place. A sample of records relating to health and safety and maintenance of the home were examined and all were found to be in order. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 26 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 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 4 33 X 34 3 35 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? no 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 YA20 Regulation 13(2) Requirement The registered person must make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines so that people living in the home are safeguarded from harm. Timescale for action 31/03/09 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 YA39 Good Practice Recommendations The manager should further develop the Quality Assurance system so that when they seek the views of people living in the home and other interested parties, the information is used to form a development plan for the home, which demonstrates that people’s views are being acted upon. Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Shrub End Lodge DS0000017930.V372255.R01.S.doc Version 5.2 Page 29 - 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!