Inspection on 13/01/06 for The Elms

This inspection was carried out on 13th January 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Elms 20/12/06

The Elms 17/10/05

The Elms 18/03/05

The Elms 21/12/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 The Elms Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ Lead Inspector Marie Carvell Unannounced Inspection 13th January 2006 10:00 DS0000033970.V270811.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 DS0000033970.V270811.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. DS0000033970.V270811.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Elms Address Ravenswood Village Nine Mile Ride Crowthorne Berkshire RG45 6BQ 01344 755575 01344 773174 theelms@norwood.org.uk bucketsandspades@norwood.org.uk Norwood Ravenswood T/A Norwood 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) ***Post Vacant*** Care Home 11 Category(ies) of Learning disability (11) registration, with number of places DS0000033970.V270811.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: The Elms is part of the Norwood organisation based at Ravenswood Village. The home is registered to provide accommodation and care for up to eleven service users, aged between eighteen and sixty five years of age. All service users have a learning disability. The range of care needs within the home is diverse and complex. Several of the service users have needs, which can challenge the service. All service users have full mobility and are able to communicate their needs and wishes. DS0000033970.V270811.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by the lead inspector for the home on a weekday from 10am until 4pm, and was unannounced. A brief tour of the communal areas of the home and several bedrooms at the invitation of service users were seen. A sample of records required to be kept in the home were examined. Time was spent with the manager designate, staff on duty and several service users. At the last inspection in October 2005, three requirements were made, these were that a weekly menu plan and records of the food choices made by service users maintained, that routine maintenance tasks in the home are carried out and that an application for manager registration is submitted to the CSCI. Two requirements have been complied with and one partly complied with. What the service does well: What has improved since the last inspection? An application has been submitted to the CSCI for registration of the manager. Some routine maintenance tasks have been completed. DS0000033970.V270811.R01.S.doc Version 5.0 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. DS0000033970.V270811.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 DS0000033970.V270811.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): None of these standards were inspected. EVIDENCE: DS0000033970.V270811.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): None of these standards were inspected. EVIDENCE: DS0000033970.V270811.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): 17 It was not evidenced that service users are provided with a varied and well balanced diet. This was subject to requirement at the last inspection. EVIDENCE: Since the last inspection a weekly menu plan and records of food choices has been put into place, however, these are not consistently maintained. Menu plans seen showed repetition of dishes with macaroni cheese being served for the midday meal on two consecutive days and three evening meal over a four day period consisted of fish fingers, fish and chips and fish pie. The manager is to review “pot noodles” as a lunchtime meal choice. The inspector was informed that service users are not involved in menu planning as service users “like sandwiches and eggs” and that food choices are restricted as most of the food provisions are from the main store on site. DS0000033970.V270811.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): 19 Some healthcare tasks are undertaken without consideration for maintaining service users dignity and privacy. EVIDENCE: During the inspection it was observed that a visiting Chiropodist was attending to service users’ feet in a communal area of the home, whilst other service users were relaxing. When asked was this usual practice the chiropodist told the inspector that it was and attending to service users in a communal area “helped the staff”. The manager designate confirmed this. During this time eight members of staff were on duty. DS0000033970.V270811.R01.S.doc Version 5.0 Page 12 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): None of these standards were inspected. EVIDENCE: DS0000033970.V270811.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26 and 30 The home is comfortable, safe and meets the needs of the service users. EVIDENCE: Since the last inspection some routine maintenance work has been carried out. Service users bedrooms are appropriately furnished and personalised to reflect the interests of the service users. The home was seen to be clean, comfortable and homely. DS0000033970.V270811.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 A competent, well trained and experienced staff team support service users. The organisation has robust recruitment procedures; some deficits were noted of staff recruited by previous managers in the home. Supervision planning and recording needs to be more robust. EVIDENCE: The home is almost fully staffed. There is a core of staff who have worked in the home for a considerable period of time and know the service users well. The organisation has a robust recruitment process, which involves prospective members of staff attending a recruitment day and assessment. All appointments are subject to a six month probationary period. No members of staff commence work until an enhanced CRB has been completed. From examination of a sample of five staff personnel files, it was evidenced that one member of staff had given a previous colleague in as a referee, but the previous employment history did not make reference to the place of work. Several files did not contain full employment history. One member of staff is working part time, with a student visa, which expired in March 2005. It was not evidenced that this has been renewed. None of the personnel files seen included a recent photograph. DS0000033970.V270811.R01.S.doc Version 5.0 Page 15 Staff training is well organised centrally, staff training and career development is actively promoted. Supervision records seen were poorly maintained. Staff receive a written supervision contract, however, these are not adhered to. One member of staff had only minutes of one supervision in 2005, and two in 2004. Not all supervision records requested were available for examination by the inspector. The manager designate confirmed that all staff with supervisory responsibility have received training in supervisory skills. DS0000033970.V270811.R01.S.doc Version 5.0 Page 16 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 and 42 The home has been without a registered manager since mid 2003. This was subject to requirement at the last inspection. Records relating to health, safety and fire were seen to be up to date. EVIDENCE: Since the last inspection the CSCI has received an application to register the manager designate. The manager designate was described by a member of staff as fair, approachable and someone who interacts well with service users. Other members of staff said that the recruitment of a full time manager was viewed positively. Since the manager designate has been in post staff morale has improved and this has had a positive impact on service users and staff in the home. The manager designate agreed to record the hours he works, as staff are not always aware when he is on duty. DS0000033970.V270811.R01.S.doc Version 5.0 Page 17 Records required to be kept in the home relating to health, safety and fire were well maintained and up to date. Accident records are maintained in accordance with the Data Protection Act 1998. DS0000033970.V270811.R01.S.doc Version 5.0 Page 18 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 x x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x 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 3 x 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 2 x x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 3 x DS0000033970.V270811.R01.S.doc Version 5.0 Page 19 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 YA17 Regulation 16 and Sch.4.13 Requirement The manager designate must ensure that a weekly menu plan is maintained and records the food choices made by service users. Previous timescale of 07/11/05 not met. That manager designate must ensure that healthcare is provided to service users in such a way as to respect dignity and privacy. That the manager designate advises CSCI of action taken to ensure that this standard is being met. That the manager designate advises CSCI of action taken to ensure that this standard is being met. Timescale for action 27/01/06 2. YA19 12 14/01/06 3. YA34 19 27/01/06 4 YA36 18 27/01/06 DS0000033970.V270811.R01.S.doc Version 5.0 Page 20 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 DS0000033970.V270811.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000033970.V270811.R01.S.doc Version 5.0 Page 22 - 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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