Inspection on 08/05/07 for Shrub End Lodge

This inspection was carried out on 8th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 4 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 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

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Grangewood

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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 Wolton-Harragan Key Unannounced Inspection 8th May 2007 10:30 Shrub End Lodge DS0000017930.V336482.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.V336482.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.V336482.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 Vacant Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Shrub End Lodge DS0000017930.V336482.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 11th October 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 ranges from £464 to £547, 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.V336482.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows a key inspection of Shrub End Lodge that included an unannounced visit to the service on May 5th 2007 and a second visit on May 22nd 2007. The judgements made within this report are based upon evidence found on the inspection visits along with information submitted by the service and feedback from service users, staff and other parties since the previous inspection. Mrs Mallek Gulabkhan, the proprietor and acting manager of Shrub End Lodge, was available throughout the inspection visits and took an active role in the inspection process. During this inspection 29 of the 43 applicable standards were looked at; 25 of these were met and four were nearly met. During the visit to Shrub End Lodge, people living at the home and staff were spoken with. All were positive about the home and the people living there appeared at ease and were happy to talk to the Inspector. Interactions between staff and the people living at Shrub End Lodge observed during this inspection were positive. The visits to Shrub End Lodge included an environmental tour of the home, discussions with people living at the home, staff and the home manager, as well as the opportunity to look at records of how people living at Shrub End Lodge were supported and how the staff were recruited and trained. What the service does well: Staff at Shrub End Lodge were positive in their approach to their work and worked well together to meet the needs of those living at the home. The staff respected the needs and rights of those living at Shrub End Lodge. The physical, emotional and social needs of the people were assessed and documented with regular reviews of care plans and risk assessments. All people living at Shrub End Lodge had full and varied programmes of activities throughout the week that included work and college and told the inspector that there were opportunities for shopping and social trips at evenings and weekends. People were supported to take part in household tasks and all took some level of responsibility for keeping their own rooms clean. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shrub End Lodge DS0000017930.V336482.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.V336482.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, 2, 4 & 5 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 and their representatives, as well as those seeking to live there, have the information needed to choose a home which will meet their assessed needs and aspirations. EVIDENCE: Shrub End Lodge has not admitted anyone since the last inspection and those living there have done so for a number of years. Discussions with the proprietor indicated that anyone who was seeking to move into the home would have their needs assessed to ensure Shrub End Lodge was appropriate for the person and that the home could meet their needs and aspirations. Part of this process would include the opportunity for the individual to visit the home and to stay for an afternoon, a day and then a weekend before deciding whether to move in. The admission would then be on a three-month trial basis before the person would need to decide if they wished to stay permanently. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 9 The examination of records showed that each person had an individual contract or statement of terms of conditions with the home as well as a copy of the service user guide. The service user guide and statement of purpose contained sufficient information for someone seeking accommodation at the home. Shrub End Lodge DS0000017930.V336482.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, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: Records for those living at the home were sampled during the inspection and showed that individual needs were assessed and were reflected within individual service user plans. These plans were subject to regular monitoring and review and changes in needs were identified and acted upon. The examination of records and discussions with people living at the home gave evidence that they were central to the decision-making processes within the home as well as playing a primary role within the care review system in place. There were regular service user meetings held at Shrub End Lodge and minutes of these were available. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 11 Records showed that risk assessments had been undertaken and risks were managed and reviewed appropriately. Shrub End Lodge DS0000017930.V336482.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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: All the people living at Shrub End Lodge had full programmes of daytime activities. These activities included work and education placements as well as individual shopping and shopping for the home. The home also undertook regular activities at evenings and weekends according to the needs and choices of individuals. Those living at the home reported that they often went to the local pub and two people were active members of a church near the home. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 13 Most people had regular contact with their families and visits to the home by relatives and friends were encouraged. The Proprietor reported that there was an ‘open door policy’ at the home and visitors were welcome at any time within reason. People living at Shrub End Road said that they were able to choose how to spend their spare time. People were encouraged to participate in domestic tasks and take responsibility for keeping their own rooms tidy. This was supported by discussions with staff as well as entries in individual records. From discussions with people living at the home, it was possible to form the opinion that people felt their rights were respected. Observed interactions between staff and people living at the home showed that people were treated with mutual respect and dignity was upheld. Individual bedrooms had had locks fitted although those living at the Home had chosen not to use them and there were agreements signed by each person to support this. Discussions were individuals and the examination of records showed that a varied diet was offered with all nutritional needs being met. Staff stated that the weekly menu was compiled jointly and that those living at the home participated in the shopping and meal preparation. Shrub End Lodge DS0000017930.V336482.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive at Shrub End Lodge is based on their individual needs and the principles of respect, dignity and privacy are put into practice. EVIDENCE: Individuals spoken with were happy with the way they were supported at Shrub End Lodge and this was reflected within the care plans examined. People had an understanding of the contents of their individual plans and had contributed to their development and review. Care plans identified individual needs, as well as the choices made as to how these needs were to be met. Care plans were well detailed, regularly monitored and formally reviewed at appropriate intervals depending on individual need. There was an ongoing process of review to take account of the changing needs of individuals and the services of healthcare professionals such as community Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 15 nurses, speech and language therapists or psychologists were accessed as necessary. Medications was appropriately stored, administered and recorded and the medication policies and procedures at the home afforded protection to those living there. No one living at the home was administering or controlling their own medication at the time of this inspection. Shrub End Lodge DS0000017930.V336482.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 & 23 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 expect their views to be listened to and acted upon and to be protected from abuse, neglect and self-harm. EVIDENCE: The home had a robust complaints procedure. The adult protection policies and procedures were adequate to protect service users from abuse and where individuals presented with behaviours likely to cause self-harm, these behaviours were identified within their care plans and management strategies devised. The Proprietor had copies of the Essex Vulnerable Adults Protection Committee guidelines and would refer to these in the event of a Protection Of Vulnerable Adults issue being raised at the home. People spoken with on the day of inspection said that should they have concerns or complaints they thought these would be taken seriously by the staff and manager of Shrub End Lodge and appropriate actions would be taken. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the Shrub End Lodge cannot always expect the home to be safely maintained although they can expect it to be clean. EVIDENCE: An environmental tour of Shrub End Lodge showed that there had been improvements since the last inspection. There was new furniture in the lounge area; new dining chairs and much of the home had had new carpets laid. The environmental improvements required at the previous inspection had been attended to. However, there were environmental issues noticed at this inspection. The floor covering in the kitchen had bubbled and presented a trip hazard and there was a broken tile next to an electrical socket in the kitchen. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 18 Weeds growing between the paving slabs of the rear patio presented further trip hazards. While these issues had been addressed by the second visit to the home, and shows the proprietors willingness to comply with regulatory requirements, it demonstrated the need for the proprietor to regularly review the environmental condition of the home and to develop a planned maintenance and renewal programme for the home. All private rooms had had locks fitted although those living at Shrub End Lodge had all signed agreements stating that they did not wish to use these and were happy for the keys to be kept by the home. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Examination of staff records, as well as discussions with the proprietor and staff, gave evidence that care staff had a good understanding of their roles and responsibilities and that staff were largely qualified and competent. Staff spoken with on the day of inspection stated that training was regularly made available and the homeowner fully supported staff in meeting their training needs. All but one member of staff had attended a Common Induction Programme. Examination of staff rotas showed that staff were employed in sufficient numbers to meet the needs of those living at Shrub End Lodge creating an effective staff team. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 20 Examination of staff records showed that all appropriate checks were undertaken prior to employment of new staff and proper records were maintained. Records showed insufficient formal one to one supervision of care staff. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 21 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, 42 & 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Shrub End Lodge could generally expect the home to be adequately managed and their views to underpin review and development of the home, while their health and safety was safeguarded. EVIDENCE: There was not a registered manager in post at Shrub End Lodge at the time of this inspection. The proprietor informed the inspector that he had now retired from the National Health Service and was able to work full time at the home in the role of manager. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 22 The proprietor was advised to submit an application for registration as manager via the Commission for Social Care Inspection Regional Registration Team in Cambridge. Discussions with people living at the home and the examination of records indicated that Shrub End Lodge was managed in such a manner that considered the views of those living at the home. This was done through the home’s quality assurance process that included regular service user meetings, staff meetings and questionnaires to a range of stake holders including those living at the home, staff, relatives and other interested parties such as community nurses and social workers. The collation of these had enabled action plans for the home to be developed. The proprietor had developed a business plan that showed projected profit and loss accounts for the year. The homeowner was advised that this now needed to be developed further to show how the strategic aims of the home would be achieved. Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 23 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 3 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 3 X 2 X 3 X X 3 2 Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 Timescale for action 19/07/07 2 YA36 18 3 YA37 8 4 YA43 25 The proprietor must ensure that the home has a planned maintenance and renewal programme for the fabric and decoration of the home (the previous timescale of 31/12/06 was not met). The proprietor must ensure that 19/09/07 all staff receive formal supervision at least six times each year to ensure their effectiveness and continued development as carers. The proprietor must ensure there 19/08/07 is a suitable person registered as manager of the home. This should be either through the proprietor applying for registration as manager or the appointment of an alternative, suitably qualified and experienced person. The proprietor must ensure that 19/09/07 a business plan for the service is available to the Commission for Social Care Inspection and which is reviewed on an annual basis. (The previous timescale of 31/01/07 was not fully met). DS0000017930.V336482.R01.S.doc Version 5.2 Shrub End Lodge Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Shrub End Lodge DS0000017930.V336482.R01.S.doc Version 5.2 Page 27 - 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. 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