Inspection on 05/10/05 for Shrub End Lodge

This inspection was carried out on 5th October 2005.

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 6 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 01/03/06

Shrub End Lodge 24/09/04

Shrub End Lodge 18/05/04

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Grangewood

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Claremont House

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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 5th October 2005 09:30 Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 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 Manager post vacant Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home accommodates 6 people with learning disabilities who may also have physical disabilities. 24th September 2004 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.V255592.R01.S.doc Version 5.0 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 in October 2005, lasting 5.25 hours. The inspection process included: discussion with one service user, the acting manager and one member of staff. Tour of the premises included observation of service users’ bedrooms, bathing and toilet facilities, as well as communal and garden areas. During the course of the inspection a range of documentary evidence was sampled. Nineteen of the forty-three standards were inspected; of these nine were meet, seven were minor shortfalls, and the remaining two were major shortfalls. What the service does well: What has improved since the last inspection? What they could do better: The home’s documentary evidence to support practice needs developing. This is particularly relevant in respect of risk assessments, and the need for the home to develop a process for reviewing and keeping under review the quality of its service provision. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 6 It is advised that the registered person monitor recording of dispensed medications periodically to ensure that errors in recording are not occurring. The homes Statement of Purpose and Service users Guide both require reviewing to ensure that they are current and reflective of the service provided by the home. 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.V255592.R01.S.doc Version 5.0 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.V255592.R01.S.doc Version 5.0 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 and 5. Both the Statement of Purpose and Service Users Guide for the home require development to contain the necessary information to enable service users and other parties to make an informed choice about the home. Contracts of residency require significant development to comply with regulatory requirements. EVIDENCE: Both the home’s Statement of Purpose and Service Users Guide were sampled. Both evidenced that none of the work identified as being necessary for the documents to comply from the previous inspection had been actioned, therefore in this respect both documents fail to meet the National Minimum Standard. Two contracts of residency were sampled. Although the basis of the contracts was there, they required further development to meet with regulatory requirements. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. The care plans are now being actively followed, however they still remain basic in their design and would benefit from further development. Risk assessments are in place, however these require further development to ensure that identified risks are explicit in terms of identifying how the risk presents, and then actions to be followed in supporting the service user appropriately to ensure that the risk is kept to a minimum. EVIDENCE: Evidence was presented that indicated that care plans have been reviewed to include the progress report sheets relating specifically to the care plan being directly linked to the care plan. The progress report sheets sampled were seen to have been recorded on a daily basis. The two care plans sampled were also inspected for evidence of risk assessments. However, although these were seen to have been carried out, they were deemed to require further development to identify how the identified risk would present, and how then to support the service user best to ensure that the identified risk was kept to a minimum. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No outcomes were inspected from this section on this occasion. EVIDENCE: Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 11 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): 20 and 21. The home’s medication procedure was generally deemed to be safe. However, it is recommended that the registered person periodically sample records to ensure that recording is in order. The home needs to ensure that the wishes of service users and/or their relatives are held on file in the event of the demise of the service user. EVIDENCE: The home’s medication process was sampled during which an error was noted in the recording. All staff have received training from the local dispensing pharmacy in administering medications. The home does not maintain any medications which fall within the category of being controlled. All medications are dispensed directly from named containers which are kept locked in a cabinet in the lounge. Medications are recorded on MAR record sheets. The error identified above revolved around a medication that had been administered to the service user, but for which no record of confirming its administration could be found. However, at the time the manager contacted the respective member of staff and confirmed that the medication in question had indeed been administered. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 12 At the previous inspection the need was identified for the wishes of service users and/or their next of kin to be held on file in the event of the service user’s demise. Some evidence was seen of the home having started to address this matter, although further work remains which was discussed with the manager at the time of the inspection. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home’s complaint procedure was generally robust. However, the Adult Protection Policy would benefit from further development to ensure that it includes guidance for staff on the actions to be taken in the event of an allegation of abuse being received. EVIDENCE: The home’s complaints procedure was generally sound, timescales for responding to complaints were included, as were the contact details of the local office of the Commission for Social care Inspection. The home maintains a log of complaints received. At the time of the inspection no complaints had been received by either the home or the CSCI. The home follows the Essex County Council’s guidelines on recognising and responding to allegations of abuse. Staff spoken with spoke of having received training in this area recently. The home’s own internal abuse policy was quite basic, but did refer staff to other relevant guidance. The home’s own policy could be enhanced by including guidance on the actions to be followed by staff in the event of an allegation of abuse. A policy that simply refers staff to further guidance would not be especially helpful when dealing with a live event. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 28 and 30. Service users’ bedrooms were seen to be equipped to meet individual needs and lifestyles. Shared space was deemed to be adequate to meet the needs of the service users. On the day of the inspection the home was found to be clean and tidy and free from any offensive odours. EVIDENCE: All service users’ bedrooms visited were deemed to comply with National Minimum Standard 26. Evidence was seen of service users’ personal possessions. Bedding, curtains and floor coverings were all seen to be of a reasonable quality. The home provides a reasonable amount of shared communal space both indoor and outdoor, which was seen to be readily accessible to service users. The kitchen and laundry facilities at the home were domestic in nature, with the laundry facility being situated well away from food preparation areas; the facility was seen to have to have a sink available for hand washing. The laundry floor was covered with linoleum which was seen to be badly torn and, Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 15 therefore, posing a potential trip hazard. It was later mentioned that this hazard had been identified and is due to be replaced. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 34. The ratio of care staff would appear to currently meet the needs of service users. Evidence seen on the day of the inspection indicated that the home’s recruitment practices are generally robust in terms of protecting service users. EVIDENCE: Staffing levels at the home continue to be two carers between the hours of 9.00 am to 9.00 pm. Nights are covered by one waking night staff. The proposed manager spoke of their hours being part of the home’s hours. Discussion took place with the manager around this and the commitment necessary upon their time to complete the work necessary to raise the standards at the home. The manager felt that currently their working arrangements will enable them to fulfil this role, however should this prove difficult then serious consideration will be required to ensure that the registered manager’s hours are made supernumerary to those of the home. Three staff files were sampled pertaining to the home’s recruitment practices and were seen to contain all of the required documentary evidence required under Schedule 2 of the Care Homes Regulations. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 17 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, 38, 39, 40 and 41. The home has not had a registered manager for a considerable time, although an appointment is anticipated which it is hoped will ensure that the home has the commitment of time to ensure that the home is well run. Discussion with staff indicated that they felt that the manager was open and approachable. The home does not yet have a process for reviewing and keeping under review the quality of its service provision. The home needs to ensure that the records required under Schedule 3 of the Care Homes Regulations are maintained in service users’ files. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 18 EVIDENCE: The home has been operating without a registered manager for a considerable period of time. An appointment to this vacancy has now been made and an application for registration is being processed by the Commission for Social Care Inspection. Discussion with the acting manager, and interactions witnessed between the manager and staff, indicated a relatively clear sense of direction and leadership. The acting manager spoke of a number of views that they held on how they intended to manage and move the service forward. The home continues to need to develop and evidence a process by which the home intends to monitor and keep under review the quality of its service provision. The manager was referred to National Minimum Standard 39 for further guidance. Evidence was seen of policies and procedures being signed off by the manager. Much of the documentary evidence required under Schedule 3 of the Care Homes Regulations pertaining to service users was seen to be held on files, although some gaps were still evident. The manager was referred to Schedule 3 of the Care Homes Regulations for further guidance. Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 x x x 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x 3 x 3 x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 2 3 x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shrub End Lodge Score x x 2 2 Standard No 37 38 39 40 41 42 43 Score 3 3 1 3 2 x x DS0000017930.V255592.R01.S.doc Version 5.0 Page 20 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 YA1 Regulation 4,5 & 6 Requirement The registered person must ensure that the Statement of Purpose and Service Users Guide meet with regulatory requirements, and that both documents are kept under review. The previous timescale set of the end of November 2004 was not met. 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 set of the end of November 2004 was not met. The registered person must ensure that risk assessment data held within service users’ care plans is comprehensive. The previous timescale set of the end of November 2004 was not met. The registered person must make provision for the recording of service users’ wishes in the event of their demise. The previous timescale set of the end of November 2004 was not met. DS0000017930.V255592.R01.S.doc Timescale for action 31/12/05 2 YA5 5 31/12/05 3 YA9 14 31/12/05 4 YA21 12 31/12/05 Shrub End Lodge Version 5.0 Page 21 5 YA39 24 6 YA41 17 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 set of the end of November 2004 was not met. 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 set of the end of November 2004 was not met. 30/03/06 31/12/05 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 YA33 Good Practice Recommendations It is recommended that the registered provider keeps under review the workload of the registered manager, as to whether their working hours need to be supernumery to the staffing hours of the home. It is recommended that the home’s Adult Protection Procedure be reviewed to include clear direction to staff on the actions to be taken in the event of receiving an allegation of abuse. It is recommended that the manager periodically reviews the medication records to ensure that no errors are occurring in respect of the records. 2 YA23 3 YA20 Shrub End Lodge DS0000017930.V255592.R01.S.doc Version 5.0 Page 22 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. 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