Inspection on 17/10/05 for The Elms

This inspection was carried out on 17th October 2005.

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 no outstanding requirements from the previous inspection report, but made 3 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 13/01/06

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 7 th October 2005 1:20pm DS0000033970.V249248.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.V249248.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.V249248.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 0181 954 455 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) theelms@norwood.org.uk Norwood Ravenswood T/A Norwood ***Post Vacant*** Care Home 11 Category(ies) of Learning disability (11) registration, with number of places DS0000033970.V249248.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th March 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.V249248.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection unannounced on a weekday, from 1.20pm until 5.15pm. A tour of the communal areas of the home and several bedrooms at the invitation of the service users, were seen. A sample of service user, staff and records required to be kept in the home, including health, safety and fire records were examined. Time was spent with the majority of service users, staff on duty and the acting manager. At the last inspection in March 2005, one requirement was made that a manager is appointed and that an application for registration is made to the CSCI. A manager has transferred from another home within Ravenswood Village; however, no application for registration has been submitted to the CSCI. What the service does well: What has improved since the last inspection? A manager has been appointed and started working in the home in July 2005. DS0000033970.V249248.R01.S.doc Version 5.0 Page 6 Service user records are being reviewed and developed. The staffing structure of the home has been reviewed and this has had a positive impact on service users and the staff team. 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.V249248.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.V249248.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): 2,4 and 5 There is a detailed admissions procedure, which includes a full assessment of need and a programme of introduction to the home. Copies of contracts between the purchasing authority and service provider are kept on file, which are held at the main office. EVIDENCE: The service users have lived together for many years. Two service user’s records were examined. Information regarding the initial assessment and background information was available in the home. The acting manager described the role of the Assessment and Funding Team and the process of introduction of a service user to the home or another home within the village, which can take several months. Each service user has a copy of the home’s Service User Guide, which includes terms and conditions. DS0000033970.V249248.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): 6,7 and 9 Service users have detailed service user plans and are involved as much as possible with decision making. Appropriate risk assessments are in place. EVIDENCE: All service users have a detailed service user plan, which is in a user friendly format. These are currently being reviewed and developed, using a different format. Service users are encouraged to be involved as much as possible. Service users are encouraged to exercise their right to make decisions and choices. These are recorded. Risk assessments are in place and reviewed on a regular basis. DS0000033970.V249248.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): 12,13,15,16 and 17 Service users enjoy a wide range of activities and leisure opportunities, within the village and local community. Service users are supported to develop individual interests and hobbies. It was not evidenced that service users are provided with a varied and well balanced diet. EVIDENCE: Service users enjoy a wide range of activities and outside interests. Several service users access leisure opportunities in the community. Many service users have enjoyed holidays, with one service user travelling abroad as part of a Norwood money raising event. All service users have regular contact with friends and family. Visitors are made welcome and are able to join service users for a meal. The staff team work hard to assist service users maintain contact with friends and family. The routine in the home is relaxed and service user focused, service user preferences are recorded in daily records. DS0000033970.V249248.R01.S.doc Version 5.0 Page 11 Menus and records of food provided need to be maintained, to evidence that service users are being provided with a varied and well balanced diet. DS0000033970.V249248.R01.S.doc Version 5.0 Page 12 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): 18,19 and 20 Service users personal, physical and emotional care needs are well met. Medication is administered in a safe and appropriate manner. EVIDENCE: Service user records clearly evidence that regular healthcare checks are undertaken on a regular basis and that a wide range of healthcare professionals are in regular contact with the home. Appropriate guidelines are in place. Medication administration records were seen to be well maintained with no obvious gaps in the recordings. All staff who administer medication have received appropriate training. PRN (when required) guidelines need to be updated, the acting manager agreed to do this. Medication was stored securely in a locked cabinet. DS0000033970.V249248.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 has an up to date complaints procedure and service users are protected from abuse. EVIDENCE: Service users have a copy of the home’s complaints procedure in the Service User Guide, which is in pictorial format. Since the last inspection one complaint has been recorded. This is being addressed. Staff spoken to confirmed that they have attended training in the protection of vulnerable adults from abuse. DS0000033970.V249248.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): 24,26 and 30 The home is comfortable, safe and meets the needs of the service users. Some areas of the home would benefit from routine maintenance work being carried out. EVIDENCE: Service users expressed their satisfaction of their accommodation and the facilities available. Some areas of the home detract from the otherwise well maintained premises. Tiles need replacing in the laundry room; a bath panel need replacing and in various places around the home paintwork and plasterwork needs attention. Service users bedrooms are appropriately furnished and personalised to reflect the interests of the service user. The premises were seen to be clean, fresh, comfortable and homely. There is a daily cleaning programme in place, this was seen to be up to date and checked an signed by senior staff on a daily basis. The rear garden is enclosed and is used by service users in the warmer weather. Members of staff are hoping to develop several garden projects with service users next spring. DS0000033970.V249248.R01.S.doc Version 5.0 Page 15 DS0000033970.V249248.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): 35 Staff individually and collectively were able to demonstrate that they have the skills, knowledge and experience to effectively meet the needs of the service users. EVIDENCE: Staff on duty had detailed knowledge of the service users needs and the inspector gained the impression of a good rapport between service users, staff on duty and the acting manager. The staffing structure of the home has recently been reviewed and this has had a positive impact on the staff team. The home currently has several vacancies for C grade support workers. DS0000033970.V249248.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): 37,39 and 42 The home has been without a registered manager since mid 2003. Policies and procedures are in place. Since the appointment of an experienced manager in July 2005, care practices have been developed. Records relating to health, safety and fire were well maintained and up to date. EVIDENCE: The appointment of a experienced and qualified manager has had a positive impact on service users and the staff team, however, an application for registration must be submitted to the CSCI. Care practices have been developed, such as increased service user involvement, activities and the reviewing of service user records. Records required to be kept in the home were up to date and well maintained. DS0000033970.V249248.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 3 x 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 3 x DS0000033970.V249248.R01.S.doc Version 5.0 Page 19 Yes one 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 23 8 Requirement The provider must ensure that a weekly menu plan is maintained and records the food choices made by service users. The provider must ensure that the routine maintenance tasks in the home are carried out. That a manager application for registration is submitted to the CSCI. Timescale for action 07/11/05 2 3 YA24 YA37 07/02/06 07/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000033970.V249248.R01.S.doc Version 5.0 Page 20 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.V249248.R01.S.doc Version 5.0 Page 21 - 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!