Inspection on 25/10/05 for Eastleigh House

This inspection was carried out on 25th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eastleigh House 10/12/08

Eastleigh House 01/10/07

Eastleigh House 27/07/06

Eastleigh House 05/05/05

Eastleigh House 18/01/05

Eastleigh House 10/08/04

Eastleigh House 12/01/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Eastleigh House First Drive Dawlish Road Teignmouth Devon, TQ14 8TJ Lead Inspector Sam Sly Unannounced 25th October 2005 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 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 Stationary 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. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Eastleigh House Address First Drive, Dawlish Road, Teignmouth, Devon, TQ14 8TJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01626 776611 01626 776611 info@craegmoor.co.uk Park Care Homes (No.2) Ltd Philip Marshall Care Home 8 Category(ies) of Learning Disability (8), Physical Disability (1) registration, with number of places Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Mr Marshall to finish NVQ 4 by the end of 2005. Date of last inspection 5th May 2005 Brief Description of the Service: Eastleigh House provides care for up to 8 people with learning disabilities and additional autistic spectrum disorder. It is owned by a subsidary of Craegmoor Healthcare Limited. Eastleigh House is located in the town of Teignmouth within walking distance of the town centre, bus routes the train station. The ground floor is wheelchair accessible with stairs to the first floor and basement. Every bedroom is single and many have en-suite facilities. There is also additional toilet and bathroom facilities. There are several spacious communal rooms including a sensory room, training kitchen, activity room, lounge and dining room. There is also a large enclosed garden. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was the unannounced, and took place in the morning of a weekday in October. This is the second statutory Inspection of the year 2005/6 and to get a full over view of the Eastleigh House’s performance it is advised to read the Inspection report dated 5th May 2005 as well Time was spent talking to staff and residents and observing residents who did not use speech to communicate. The deputy Manager Laura Bigland was present during the Inspection, as the manager was not at work that day. Judgements were based on the above observation and discussion, and the examination of care, health and safety and staffing records. A tour was also made of parts of the building, but not all. Two comment cards were received from residents, and two from relatives. The comments in one of these cards were forwarded to the Owners to investigate using their complaints procedure. What the service does well: What has improved since the last inspection? Each resident has a comprehensive care plan so that staff can support them appropriately. The environment at Eastleigh is now furnished and decorated to a good standard, many, but not all, of the outstanding environmental requirements have now been met making the home safer, clean, homely and comfortable. Eastleigh now has a registered manager, and deputy manager. The deputy manager said that the Owner’s were supportive and that progress was being made towards improving the management and staffing problems affecting the home. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 6 Most staff were doing an NVQ course, and new staff completed a specialist autistic induction and foundation course. Staff said that this improved their practice and confidence. 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. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 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 standard(s) 2 & 5 Information on resident’s terms and conditions has not been agreed by, and distributed to them. New residents can be assured that their needs will be assessed prior to admission. EVIDENCE: The deputy manager was unable to advise whether contracts had been signed and distributed to residents and their representatives. Copies of contracts were not found during the Inspection. There was a comprehensive assessment format for new residents, although no new residents had been admitted for over a year. Two current resident’s assessments and plans were examined and were regularly reviewed and amended. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 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 standard(s) 6, 7 & 9 Care plans reflect the changing needs, including risks of residents and are reviewed regularly however, it could not be demonstrated that residents are always involved in the day-to-day decision making about their lives. The way the Owners handle resident’s finances did not give full protection or the best possible return on their savings. EVIDENCE: Two resident’s care plans and risk assessments were examined and were comprehensive, up to date and showed evidence of family involvement. Due to the complex needs of resident’s there was also evidence of multi-agency planning meetings, and behavioural plans. Incident reports were being analysed by the management team and informed resident’s care plans. Daily recording did not reflect that resident’s care plans and activity programmes were systematically followed. The element of decision-making within resident’s activity programmes was also not being fully explored, which meant records did not always demonstrate that residents had chosen, or been given alternatives to what they were doing each day. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 10 CSCI were aware that the Owners are continuing to work on an improved system for handling resident’s money. This is not yet fully implemented. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15 & 16 The well thought-out resident’s activity programmes are not being fully and systematically implemented, so at times resident’s activities are limited and continuity is broken. The activities that do take place make full use of community facilities and amenities, and family involvement is encouraged and supported. EVIDENCE: Each resident had an individual activity programme. A lot of time, thought and effort had been put into developing personalised, programmes to improve resident’s skills and experiences, taking into account their autistic needs, however, it became clear during the Inspection that programmes were not always consistently followed. Problems with systematically implementing the programme came from a lack of shared ownership and understanding by all staff, a lack of vehicle drivers on some shifts, staff sickness and holiday periods leaving lower staff levels and priority sometimes being given to other things; for example on the day of Inspection unplanned staff meetings meant two residents did not go on a Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 12 planned walk. The element of decision-making within the programme was also not being fully utilised which meant records did not always demonstrate that residents had chosen to do the activities they ended up doing. However, residents were doing more activities than they had done in the past, and the range of activities and experiences in and out of the home had expanded. Examples of activities were trips out, walks, using a trampoline, dog walking, water play, massage, shopping, cooking, and relaxation. All the residents had been on a holiday this year too, and residents regularly ate meals out during the week. Residents made use of the local community amenities, and the deputy manager had spent time exploring activities on offer locally, bringing information back to the Home to expand the opportunities for residents. Family involvement, where appropriate, was encouraged and integral to resident’s care plans. Resident’s kept in touch through visits, phone calls and correspondence and family members were invited to reviews. On the day of Inspection staff were observed to be interacting at all times with residents, talking to them in a respectful manner and respecting their privacy, whilst at the same time being available to support them. Learning about resident’s rights, confidentiality and privacy make up part of staff induction at Eastleigh House. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 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 standard(s) 20 Although the storage and disposal of medicines was safe, mistakes in the recording of the administration of medication put resident’s health at risk. EVIDENCE: Medication was being stored and disposed of appropriately and staff were about to attend an intensive medication training course, however on the day of Inspection two pills were being returned to the Pharmacy and records showed the medication as given to the resident. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 14 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 standard(s) 22 Residents and their representatives can feel assured that their concerns are listened to and acted on. EVIDENCE: The Commission had received one complaint about Eastleigh House since the last Inspection. This complaint was past to the Owners to investigate. It was investigated appropriately, upheld, and action taken to rectify the concerns. The Owners had also received one complaint that they were still investigating. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 15 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 standard(s) 24 & 29 The premises were on the whole suitably adapted, maintained and furnished for its stated purpose, with a system in place to meet identified deficits. However, several maintenance issues remained which could potentially compromise the safety of residents. . EVIDENCE: The premises were maintained to a satisfactory standard, after a major refurbishment programme. Communal rooms were comfortable, homely and relaxing and some bedrooms were being refurbished. The home employed a maintenance person full time. He said it was now easier to get larger maintenance budgetary spends agreed by the Owners. However several outstanding maintenance issues were found on the day of Inspection that had been picked up several Inspections ago, and several bathrooms required refurbishing. The issues identified were: railings required for the steps leading out of the computer room and resident’s kitchen, the need for the food storage room to have a separate access to the laundry, and the hanging of fire doors that the Owners had bought several months ago to replace the current fire doors in the building. It was noted that the registered manager had been obtaining quotes to get this work carried out. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 16 The deputy manager said the Environmental Health Department had visited the home recently, however the report could not be found so it was agreed a copy would be sent to the Commission. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 & 34 At times Eastleigh House struggles to maintain appropriate staffing levels, and this affects the quality of service provided to residents, however, the Owners are genuinely working to improve the situation. Resident’s benefit from a staff team that are fit to work with them, approachable, interested and committed and that receive a range of training tailored to their needs. EVIDENCE: The staff on duty were approachable, interested and committed to the residents. Staff said they had received a range of training, and a new staff member was working through a comprehensive induction and foundation course. The Owners had also introduced an induction to working with people with autistic spectrum disorder, but it was unclear at Inspection how many staff had done the course. Staff received training on protection of vulnerable adults and working positively with challenging behaviour. Most staff were doing NVQ training, and the NVQ trainer visited the home on the day of Inspection. Staff said they enjoyed their work. Staff, especially the seniors, had a range of skills and experience that, from discussion with the deputy manager, were going to be better utilised in the future by the registered manager delegating some of the management tasks. Regular staff meetings were taking place and supervision was about to be re-introduced. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 18 There were still, at times, problems with staffing levels, which included covering staff sickness and holidays and staff turnover. The Owners and registered manager were fully aware of these problems and working together to try and improve the situation. Several staff files were examined and found to be comprehensive and include all the appropriate fitness and identity checks. It was recommended that a debriefing session be always recorded after any incident where a resident injures a member of staff. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 39 The Owner and Registered Manager are working towards ensuring Eastleigh becomes a well run home. The Owners methods for monitoring quality were not underpinned by resident’s views, and did not enable them to identify, overall, what they were doing well and what needed to be improved. EVIDENCE: Eastleigh House now has a registered manager and he is working towards gaining the required qualifications. Staff said that the registered manager has begun to make himself more available to them, and is learning the skills required to make a good manager. They still felt their skills were under utilised however, and were keen to be delegated more responsibility and be more involved in the day-to-day running of the home. The deputy manager showed a good understanding of the specialist needs of residents. The Owners are currently working on a quality assurance system that meets CSCI requirements, and have said a draft will be available soon. The regional Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 20 manager visits Eastleigh House on a regular basis and reports to CSCI monthly. Other quality checks take place too. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 21 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 x 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 2 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x 2 x Standard No 11 12 13 14 15 16 17 x 2 3 2 3 3 x Standard No 31 32 33 34 35 36 Score x 3 2 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Eastleigh House Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x x x D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 5 Regulation 5 (c) Requirement Contracts must be signed by residents or their representatives and distributed. (Previous timescale of 25th February 2005 & 20th July 2005 not met). Daily records should reflect that residents are involved in the decision-making about what they do each day including their activity programme. The Owners should put into place the banking arrangements for residents that have been proposed. (Previous timescale of 31st March 2005 & 20th July 2005 - not met) Residents activity programmes must be fully implemented to give continuity and choice. Medication administered by staff must be administered and recorded safely. The Owners must make sure rails are provided on steps that residents use to get out of the building (Previous timescale 31st March 2005 & 20th July 2005 not met). The programme, with timescales, for the Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 23 Timescale for action 31/12/05 2. 7 12 (2) 31/12/05 3. 7 20 31/12/05 4. 5. 6. 12 & 14 20 24 & 29 12 (1) 13 (2) 13 (4) 23 (2) 31/12/05 25/10/05 31/11/05 environmental issues identified on the Inspection must be sent to the Commission, and the work must be carried out. 7. 8. 33 39 18 24 There must be sufficient staff on duty at all times to meet the needs of residents. There must be a complete Quality Assurance system in place which captures the views of the residents and stakeholders. An annual report must be produced, with a copy available for CSCI and other interested people (Previous timescale 16th March 2005 &20th September 2005 not met) 31/03/05 31/03/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 6 33 Good Practice Recommendations Daily records should reflect that the residents care plans and activity programme are being followed. A recorded de-breifing session shuld take place after any incident when a staff member is injured. Eastleigh House D54-D07 S32594 Eastleigh House V241761 251005 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon, TQ13 7UP 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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