Inspection on 25/01/06 for East Court

This inspection was carried out on 25th January 2006.

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

East Court 28/09/06

East Court 02/08/05

East Court 14/02/05

East Court 22/10/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 East Court Doctors Hill Wookey Wells Somerset BA5 1AR Lead Inspector Sally Murphy Unannounced Inspection 25th January 2006 11:45 East Court DS0000015998.V280331.R01.S.doc Version 5.1 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 East Court DS0000015998.V280331.R01.S.doc Version 5.1 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. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service East Court Address Doctors Hill Wookey Wells Somerset BA5 1AR 01749 673122 NA 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) THE ORCHARD VALE TRUST Care Home 17 Category(ies) of Learning disability (17) registration, with number of places East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 Brief Description of the Service: East Court is a large listed building located on the edge of Wookey. The house is set in extensive grounds which include a productive vegetable garden. Accommodation in provided in four units. The main house accommodates nine people; stable cottage is shared by two, the coach house offers two separate bed sits, and the garden house offers a quieter environment for four people. All service user rooms are single occupancy and fifteen have en suite facilities. Service users are encouraged to develop and maintain daily living skills and are able to participate in a wide range of activities. East Court is registered with the Commission for Social Care Inspection to provide accommodation for up to seventeen people with a learning disability aged 18-65 years. The Manager is Ms Lesley Reece, who has applied to the Commission for Social Care Inspection to become the Registered Manager for the home. The Registered Provider is Orchard Vale Trust. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the planned annual programme of inspection. The inspection was unannounced and carried out by one inspector over one day. The previous inspection was announced and took place on 2nd August 2005. On the day of the inspection there were seventeen service users residing at the home. During the course of the visit service users, relatives, staff members, Registered Provider and Manager Designate were spoken with. Care practice was also observed, records examined and a tour of the premises was made. What the service does well: What has improved since the last inspection? Since the last inspection Robert Freebury has taken over the role of Responsible Individual for Orchard Vale Trust. Lesley Reece, who is an experienced member of staff at East Court, has been appointed as Manager and is in the process of making an application to CSCI to become the Registered Manager for the home. There has been an on-going program of re-decoration and refurbishment within the home. Since the last inspection a new kitchen has been installed, and new appliances purchased. There are plans to upgrade further areas within the home. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 6 Polices and procedures are being systematically reviewed to ensure that they reflect best practice. The Management staff from East Court and Northcroft have begun holding monthly meetings, to improve and standardise systems within the homes owned by the Orchard Vale Trust. 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. East Court DS0000015998.V280331.R01.S.doc Version 5.1 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 East Court DS0000015998.V280331.R01.S.doc Version 5.1 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, 2, 3, 4 & 5. Service users and their families are provided with appropriate information to make a decision regarding admission to the home. The home has developed an appropriate Admissions procedure. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide details of the services and facilities offered at East Court. The home has an Admissions policy. Service users are admitted on a threemonth trial basis. There have been no new admissions to the home for several years. A copy of the service user contract was provided. This clearly states which services are included within the weekly fee, and provides details of any notice periods required. East Court DS0000015998.V280331.R01.S.doc Version 5.1 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, 8, 9 & 10. The home has developed a detailed care plan for each service user. Service users are encouraged to exercise choice and are consulted appropriately. Service users participate in all aspects of life within the home. Records relating to service users are appropriately maintained. EVIDENCE: Care plans are maintained for each service user. Two care plans were examined in detail. Care plans provide details of service users needs, daily routines and preferences. Service users are able to access their care plans, and may store these in their bedroom, or the office, as they prefer. Risk assessments are completed as required. Care plans are reviewed and updated appropriately. Service users are encouraged to exercise choice regarding the activities they participate in and their daily routine. Service users have a key worker. Service users have been able to spend a short time in the one of the bed-sits to gain experience of living more independently. Once all of those service East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 10 users who have expressed an interest in living there have had a trial stay, one person will have the opportunity to move there on a permanent basis. Service users views are sought on a regular basis at the residents meetings. Service users have been consulted regarding plans to celebrate the 20th Anniversary of East Court, and have chosen the activity and venue for this. The home plans to put up a notice board in the hallway which will display which members of staff will be on duty each day. The home assists eleven service users in managing their monies. Records are maintained of all transactions involving service user finances. These are supported by receipts and staff signatures and are audited on a daily basis. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 11 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, 14, 15, 16 & 17. Service users are able to participate in a wide range of activities, and have regular opportunities to access the local community. Independence is promoted. Service users are encouraged to develop and maintain daily living skills. Meals provided are of a high standard and offer a well balanced diet. EVIDENCE: Service users are able to participate in a wide range of activities. The facilities provided at East Court include a pottery, bakery, weavery and a large vegetable garden. There is also a further workshop nearby where service users may participate in Batik. Service users are also provided with regular opportunities to access the local community, to attend a number of clubs and activities. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 12 The home has an Activities Co-ordinator. She works with service users to ensure that the range of opportunities offered continues to meet service users interests and needs. An Activities Week is held each year, where service users may try out a wide range of activities. The home provides service users with £150 each year towards a holiday. Service users go away in small groups, and are involved in choosing and planning the breaks. Previous holidays have included stays in Normandy, Guernsey, Cornwall and Blackpool. Some service users attend college. Service users are encouraged to develop and maintain independence. Two service users at the home are in employment. Service users are fully involved in the growing, preparation and cooking of foods. A new kitchen has recently been installed at the home. This has improved the facilities and increased opportunities for service users to participate in meal preparation. Some staff and service users at the home belong to the Healthy Living Club. Meals are seen as an opportunity to meet up and enjoy social interaction. Service users spoke highly of the meals provided. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 13 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 & 20. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. The home has an appropriate medications policy. All medications are stored securely. EVIDENCE: Service users are provided with support to undertake personal care tasks as necessary. The level and type of assistance required is specified in their care plan. Staff support service users in accessing health care services, and ensure that specialist advice is sought as required. Care plans included epilepsy and behavioural management guidelines. A record is maintained of all professional visits. The home has a medications policy. Senior staff are provided with medications training. On the day of the inspection, an Immediate Requirement was issued stating that hand written entries on Medication Records must include the date and quantity of the medication, and be confirmed by a second staff signature. A signature had been recorded for all medications given. The home has East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 14 provided appropriate supervision and monitoring is provided to those service users who self-medicate. All medications are stored securely. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 15 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 & 23. The home provides service users with regular opportunities to provide feedback on the service provided. The home has developed an appropriate complaints procedure. The home has policies relating to the Protection of Vulnerable Adults and whistleblowing. The Public Disclosure policy must be reviewed. EVIDENCE: The home holds monthly meetings where service users may express their views. Service users confirmed that they enjoyed these meetings and felt that their views were listened to. Since the last inspection the home has developed a new complaints procedure, which includes details of external agencies that may be contacted, including CSCI. This is displayed on the noticeboard in the hallway, and has also been discussed at a recent service user meeting. The home has policies relating to the Protection of Vulnerable Adults and Whistleblowing. The current Public Disclosure policy contained within the staff handbook does not contain details of external agencies that staff may contact. The home must review this policy to ensure that it complies with the Public Disclosure Act 1998. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 16 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, 25, 26, 27, 28, 29 & 30. The home has been decorated and furnished to a high standard. A range of accommodation is provided at the home. There are sufficient communal areas to meet service users’ needs. Service user rooms have been decorated to reflect individuals’ lifestyles and needs. The home is maintained to a high standard of cleanliness. EVIDENCE: East Court is a large listed building, situated within spacious grounds. Accommodation is arranged in four units. The main house accommodates nine people; stable cottage is shared by two, the coach house offers two separate bed sits, and the garden house offers a quieter environment for four people. Staffing levels are provided to each unit in accordance with service user need, enabling some service users to live with greater independence. Service users’ rooms have been decorated and furnished to a high standard. Each is room single occupancy and fifteen have en suite facilities. Service users are fully involved in choosing the décor for their rooms. Those service East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 17 user rooms seen had been individualised with photographs, pictures and personal belongings. All service user rooms have locks fitted. There are separate communal areas within each of the units, and an additional games room within the main house. The home is set in large grounds that are accessible to service users. The home also has a guest room that is available for visitors. There is an on-going program of re-decoration and refurbishment within the home. Since the last inspection a new kitchen has been installed. One of the bed-sits is being re-decorated, and there are further plans to re-configure the office. The home was found to have a high standard of cleanliness, and follows good practice with regard to infection control. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 18 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): 31, 32, 33, 34, 35 & 36. Staffing levels are appropriate to meet service users’ needs. Staff are competent and provide a high standard of care. Staff are provided with opportunities to attend training, and receive regular supervision. The home must ensure that appropriate information is obtained prior to a staff member commencing employment at the home. EVIDENCE: Duty rotas are maintained. There are generally four staff on duty during the day, in addition to two sleeping-in members of staff at night. The high level of staffing has ensured that service users are provided with regular opportunities to participate in social activities and access the local community. Newly appointed staff receive Induction training. Staff are provided with regular updates in mandatory training, and have recently attended training sessions over the Christmas period. The home has recently purchased a training package, which will enable staff to cover a range of courses including fire safety, first aid and infection control. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 19 The home plans to appoint additional senior carers to the staff team. Staff spoken with stated that it was a good place to work and that they received appropriate support. Staff receive an Individual Performance Review, and receive supervision on a regular basis. The recruitment files were examined for the three members of staff employed since the last inspection. Two references had been obtained for two staff members, but only one reference had been received for the third person. None of the files examined included evidence of a POVA First check being obtained, and two of the staff members had started work before the Enhanced CRB disclosure had been obtained. For the protection of vulnerable service users two satisfactory references and a POVA First check must be received prior to a member of staff commencing employment at the home. Staff may then work with appropriate supervision until the Enhanced CRB disclosure is obtained. Recruitment records did not contain evidence that the staff member was mentally and physically fit to undertake work at the care home. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 20 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, 41 & 42. The home is well run. There are appropriate systems in place for consultation with service users and their families. There is a relaxed and open atmosphere within the home. Appropriate actions have been taken to promote the health and safety of staff and service users. EVIDENCE: Lesley Reece has been appointed as the Manager at East Court, and is in the process of applying to CSCI to become the Registered Manager for the home. She has a good knowledge of the service users needs and continues to work one shift each week. Robert Freebury, the former manager has become the Responsible Individual and regularly visits all of the homes owned by the Orchard Vale Trust. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 21 Service users and their families are encouraged to provide feedback on the service provided. Service User meetings are held each month, and Family meetings every three months. The families of service users at homes within the Orchard Vale Trust also choose a Families Representative to liaise with the Trustees. The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. The home displays appropriate Employers Liability Insurance. One member of staff has taken lead responsibility for health and safety within the home. Fire records were examined, and had been appropriately maintained. Staff are provided with regular fire safety training. Health and safety records have been appropriately maintained. All accidents have been recorded and reported as required. East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 22 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 4 2 3 3 3 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 2 ENVIRONMENT Standard No Score 24 4 25 3 26 3 27 3 28 4 29 3 30 3 STAFFING Standard No Score 31 3 32 4 33 4 34 2 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 4 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 X 3 3 4 3 3 3 X East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? na STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Hand written entries must include the date and quantity of medication, and be confirmed by a second staff signature. The current Public Disclosure policy contained within the staff handbook does not contain details of external agencies that staff may contact. The home must review this policy to ensure that it complies with the Public Disclosure Act 1998. Two satisfactory references and a POVA First check must be received prior to a member of staff commencing employment at the home. Staff may then work with appropriate supervision until the Enhanced CRB disclosure is obtained. Recruitment records must contain evidence that the staff member is mentally and physically fit to undertake work at the care home. Timescale for action 25/01/06 2 YA23 13(6) 01/03/06 3 YA34 19 & Schedule 2 25/01/06 East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 24 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 East Court DS0000015998.V280331.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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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