Inspection on 28/11/05 for Eastry Villas

This inspection was carried out on 28th November 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eastry Villas 30/01/07

Eastry Villas 11/07/05

Eastry Villas 01/02/05

Eastry Villas 26/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Eastry Villas High Street Eastry Sandwich Kent CT13 0HE Lead Inspector Michele Etherton Announced Inspection 28th November 2005 09:45 Eastry Villas DS0000048300.V257837.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 Eastry Villas DS0000048300.V257837.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. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eastry Villas Address High Street Eastry Sandwich Kent CT13 0HE 01304 611600 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) Family Care Homes Ltd Miss Rosemary Chapman Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Restricted to Ten (10) beds until completion work of additional two (2) bedrooms at Forge House site. 7th July 2005 Date of last inspection Brief Description of the Service: Eastry Villas is the collective name for three small units on or adjacent to the Eastry House site, owned by Family Cares Homes Ltd. The units are individually known as Mill House, Gore House and Forge house and are incorporated into one registration to be known jointly as Eastry Villas. Forge house is a small semi detached period property adjacent to the car park of Eastry House, the property is registered to provide accommodation for up to 4 service users with learning disabilities who have achieved a degree of independence that enables them to undertake most of the daily household tasks with minimal staff support. Only two bedrooms are currently registered, planning for two further beds is currently under consideration. Gore House is a detached house for three service users, (currently all female) who have some challenging and complex behaviours. Mill House is a detached unit for five service users (currently all male) with challenging and complex behaviour. All three units’ have sleep in staff. All bedrooms are single occupancy. It is an expectation that service users in the units will undertake some household tasks for themselves or with support. Limited car parking is available in the Eastry house car park or in the village. Service users of all three units have their own gardens but have access to the day centre on the Eastry site. Both Mill and Gore houses have downstairs bedrooms, but without additional alterations to both premises independent wheelchair users would find their movement and access to gardens etc restricted through environmental limitations. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that commenced at 9.45 a.m. and finished at 5.40 p.m on the first day of inspection, a short follow up visit was arranged for 1/12/05 to clarify staff recruitment procedures not covered on the first day and lasted approximately 1 hour. The inspection was carried out as part of the annual inspection programme; the focus of this inspection being to assess progress made by the home since the last inspection in addressing outstanding requirements and recommendations, and to assess remaining key standards. The inspector spent time in each unit, touring the premises, and chatting with residents and staff, a varied range of documentation was reviewed in each unit. During the visit the inspector spoke with nine of the current residents across all three units, and seven staff. In addition the registered manager and a provider were also spoken with. The views and feedback of all of these groups in addition to that received from two relatives spoken with at inspection and from relatives inspection comments cards has contributed to the compilation of this report. What the service does well: What has improved since the last inspection? The inspection highlighted that there have been some staff changes since the last inspection, and that the registered manager is more closely involved with each unit than previously; feedback from care staff in the units is very positive at this change. Staff feel there has been an improvement in communication and that the units are starting to work well together. The units have worked steadily towards achieving the outstanding requirements and have currently achieved six out of nine, with a further requirement partially addressed. Two requirements in respect of staff induction and quality assurance remain unmet at this time although a number of quality Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 6 assurance systems are in place in the main House these are still to be extended to the smaller units. In addition seven of the twelve previous recommendations have been addressed with a further one partially addressed. 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. Eastry Villas DS0000048300.V257837.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 Eastry Villas DS0000048300.V257837.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): 1,2,4 Prospective service users’ benefit from having updated and detailed information about the service they may choose to live in, and that their needs are assessed prior to admission. Opportunities are provided for prospective service users to experience introductory visits and stays at the home to inform their decision and support the assessment process. EVIDENCE: Following the recent re-registration of the three units Mill, Gore and Forge into the single registration for Eastry Villas, there was a need for the Statement of Purpose and service user guide to accurately reflect the change and a requirement was issued to this effect. The inspector viewed the amended documentation and was satisfied that this has now been addressed and documentation provided is currently accurate. A previous recommendation for the units to clarify arrangements within the documentation for smokers has also now been addressed. Although no new long-term admissions have been made to the home since the last inspection, a prospective service user is currently being assessed for the remaining vacancy with a view to admission early next year. Documentation viewed on the second day of inspection provided evidence that a detailed assessment had been undertaken which also drew on the knowledge and experiences of other people currently involved with the service user. In keeping with the needs of the service user the process of assessment is ongoing with a phased introduction to the home through visits and weekend Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 9 stays. Staff’ spoken with at inspection were confident that the service could meet the needs of the prospective service user Feedback from staff across all three units confirmed that the client care department is involved in the selection of prospective service users, and that once selected a workshop is established for staff to attend that addresses the needs of the prospective user and how they are to be met by the service. Whilst this is a good system for ensuring staff are familiarised with needs and given guidance on how support is to be given, staff have little input into the initial selection process, and in some instances feel that potential selections have or could have compromised the lifestyles of existing service users detrimentally. The inspector discussed concerns with the manager that decisions regarding selection of prospective service users are still being taken in isolation by the client care department without fuller consultation with staff. The inspector has recommended improved liaison with respective units to ensure the views of staff are taken full account of in the selection process to ensure needs can be adequately met, and that the needs of existing service users are also considered. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Progress has been made to ensure that care plans and risk assessment information reflecting needs and goals are updated and endorsed by service users and other stakeholders. Service users with limited communication would benefit from communication programmes to support decision-making. EVIDENCE: The home has worked hard to implement wider consultation with other stakeholders in respect of care plan information and have addressed an outstanding requirement. All nine care plans were reviewed and three are still awaiting signatures from other stakeholders to whom they have been sent. Those service users who are able to sign their own care plans confirmed that these are read with them and they are currently satisfied with their content. Behaviour management strategies and risk assessment information is also being forwarded by the home to other stakeholders to endorse, and this will be repeated should there be significant changes to any of this documentation during the year. Additional workshops are provided to support staff in working with specific service users where issues arise. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 11 The home has since the last inspection changed its procedure for recording behaviour incidents, and addressed an outstanding recommendation. The review of the previous system has ensured that all units now work to the same procedure, and that the client care department who analyse them deals with ‘incident’ reports consistently. Feedback from discussions with service users in all three units indicated that most, actively make decisions about their daily lives and routines seeking support where needed. Decision-making amongst the less able service users is more difficult to assess, particularly as communication programmes are not in place to facilitate this. In response to a previous recommendation the home were able to evidence that a referral for speech and language input has been requested in respect of two service users. Discussion with service users during tours of all of the units indicated opportunities for service users to make decisions in respect of the personalisation of their bedrooms and influence decoration and furnishings in keeping with their own preferences. Feedback through inspection comment cards and discussion with relatives highlighted some concerns, that service users were actively choosing not to participate in some activities that parents viewed as important, this sometimes brings parents into conflict with the service who try to support the service users in making decisions and choices for themselves. The inspector was satisfied from discussion with specific service users that they are satisfied with the choices they have made. Concerns’ at weight gain in respect of some service users was an issue raised with the inspector by relatives, who felt that staff needed to more actively encourage users to participate in more physical activities. The home has identified that there has been a weight gain amongst some service users, and have implemented measures to try and address this in all three units that includes, reviewing the content of the weekly shopping for the units, implementation of a healthier menu and improved access to physical activities i.e. Use of Gymnasium and swimming pool facilities. The home has responded to a previous recommendation to review and update risk assessments, a range of these were viewed on user files. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users are supported to maximise their potential for independence and to develop daily routines in keeping with their own choices. EVIDENCE: Discussion with service users indicated that the majority have access to a varied range of activities weekdays and weekends which they enjoy, all of those users spoken with who were able to make their views known expressed general satisfaction at their present lifestyle and some spoke of identified goals. Routines appear generally relaxed except on those days where users have work or college commitments. Service users in all units indicated varying degrees of responsibility for undertaking household tasks, whether this be cleaning their room, helping in the kitchen, with shopping, getting errands from the local shop etc. The home has addressed an outstanding recommendation in respect of locks on doors, service users have been asked their preferences and locks have been installed where service users have requested this. Two service users in Mill who currently have chosen not to have locks were spoken with, one confirmed their wish not to have a lock and this was consistent with their expressed Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 13 views at previous inspections, this is also recorded on their file; another user spoken with had decided against a lock but with hindsight now wished to have one installed and this is to be arranged for them by staff. The inspector recommended that locks should be routinely fitted rather than offered as an option, service users can then choose whether they wish to make use of them or not Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Staff have a good understanding of the needs and preferences of the service users and provide support where needed. Access to routine and specialist healthcare support is facilitated for service users. Shortfalls in the administration and recording of medication could place users at risk. EVIDENCE: The inspector was satisfied from discussion with users and staff that personal care routines are flexible and in keeping with the personal preferences made known by service users, the mix of staff in the units was appropriate to the age and gender of the service user groups. Discussion with staff indicated clear understanding of the appropriateness of same gender personal care support where possible, and male staff spoken with indicated they would seek input from female staff to support female service users to ensure their privacy and dignity was upheld. The home has addressed a previous recommendation for referrals to be made to health professionals on behalf of a resident requiring OT re-assessment and also speech and language input. User files viewed provided evidence of routine and more specialised health care appointments. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 15 The home is still to fully meet an outstanding recommendation in respect of handwritten changes to MAR sheets, whilst handwritten transcriptions are being correctly recorded on to MAR sheets, other changes to MAR sheet information noted at inspection had not been signed or dated, and there was no supporting documentation as to why these changes had been made. A previous recommendation in respect of improved storage of medication, the dating of liquid medications upon opening and the development of specimen signature lists for administering staff have been addressed, the home is still to implement recommended daily temperature checks of the medication storage area. Discussion with a staff member at Gore House indicated there might still be some confusion in respect of medication training and when a staff member is able to administer medications. Whilst there was no evidence to suggest otherwise and administering staff have not only a one day course but also a more in depth course supported by the local college, they were reminded that no staff member should be administering medications unless they have received accredited medication training and have been assessed competent to do so by their manager. This was discussed with the manager to ensure that staff in all units are clear about this. The inspector viewed the MAR sheets for all three units, whilst generally these are much improved; there are still some recording omissions. Two minor medication errors ere noted, where there is inadequate recording to establish what actions have been taken to address the error and ensure the safety of the service user concerned. It remains an outstanding requirement for the home to address these shortfalls. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users benefit from access to a satisfactory complaints procedure that they are confident to use. The absence of meaningful input by care staff into the development of behaviour guidelines could compromise their effectiveness and place users and staff at risk. EVIDENCE: The complaints record was viewed on this occasion, one complaint has been received since the last inspection from two service users, this has been thoroughly investigated and resolved, the inspector was satisfied that the home has a robust procedure for the investigation of complaints and that more able service users feel confident it using the procedure. The home has taken on board issues raised in a previous recommendation in respect of wider consultation with other stakeholders in respect of behaviour management guidelines, and obtaining endorsement of strategies put in place, by those stakeholders. Despite previous expressions of concern that staff’ in units have little influence on the development of behaviour management guidelines for individual users, this inspection highlighted that there has been little improvement in this area. Feedback from staff suggests that they have an expectation of better communication with the client care department that is not currently realised. Staff would like a more flexible working partnership that provides opportunities for them to routinely feedback what works and what doesn’t work. It is acknowledged that staff have in depth knowledge and experience of working with individual service users, attempts to implement guidelines without reference to staff however, could compromise the health and welfare of service users or other service users and staff, be unrealistic and ineffective It is a requirement that development of behaviour management guidelines is Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 17 undertaken with the involvement of the care staff involved and that the home can evidence this involvement. The home has the professional input of a psychiatrist in reviewing the management of behaviours through the review of medication, however, this should be only one aspect of developing appropriate and effective behaviour management strategies, it is strongly recommended that the client care department should give equal if not greater consideration to the input of behavioural psychologists in the development of guidelines and strategies to minimise inappropriate behaviours. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 18 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): 24-30 The units are clean and well maintained. Service users will benefit from the current and ongoing planned programme of upgrading to improve facilities and make a more comfortable, homely and safe environment. EVIDENCE: Window restrictors have been fitted in some first floor rooms in all the units, and risk assessments drafted for those rooms without restrictors. Mill house The home at Mill house is undergoing some structural alterations some of which have already occurred, plans have been provided to CSCI indicating the recent changes and proposed changes, a schedule of accommodation has now been provided and this is under review by CSCI to ensure changes to accommodation does not adversely compromise personal and communal space available to service users. A staff and visitor toilet on the first floor of Mill house is still in need of a hand-wash facility and this is currently under review and its’ upgrading contained within the homes development plan. The home environment is being improved by the addition of pictures, plants etc to make it more homely. At the time of the inspection a large lounge window had been broken accidentally and was awaiting replacement, this was appropriately Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 19 boarded and as it contained safety glass there was a low risk to service users. The inspector has been advised that the window has now been replaced. Forge House A new cooker has been installed at Forge House. Plans for the addition of a further two places at Forge are still with the planning department. The unit is well maintained and furnished in a comfortable and domestic style to a very good standard. A review of user bedrooms at Forge house (with their permission) and a subsequent discussion with them about their rooms confirmed that a previous recommendation to ensure both users had an easy chair provided in their bedroom has been addressed to their satisfaction. A star key lock has been removed from the front door of Forge House. Gore House. An outstanding requirement for the home to review toilet facilities at Gore house has been undertaken, these have been repainted. It is a recommendation however, that consideration is given in any further development of the building for a change to the design of the toilets on both floors, as their current design could compromise infection control, measures in the house. Water damage to a downstairs bathroom ceiling has dried out and would benefit from a repaint. A previous recommendation to review the appropriateness of a downstairs bedroom in Gore house used by a service user in a wheelchair, has taken place. This inspection highlighted that changes to the furnishings in the room and layout improvements had significantly improved the use of space in the room, the bedroom was more personalised and comfortable with good quality fabrics and furnishings, this had also enabled another requirement that the users chest of drawers be moved from the bathroom to their bedroom to be addressed satisfactorily As a consequence of these changes previous concerns about independent wheelchair movement in the room have been somewhat alleviated, although movement out of the building independently is restricted owing to the presence of door frame ledges. At present owing to improvements in the service users independent movement around the home without use of the wheelchair, this is no longer a pressing issue, it is suggested, however, that this situation is kept under review in the event that the service user once more becomes more dependent on a wheelchair. A recommendation that an upstairs bedroom currently lacking stimulation and personalisation be upgraded is still to be addressed. A window has been installed to a downstairs bedroom that previously lacked ventilation, Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 20 The home has addressed an outstanding requirement for a bath hoist at Gore house to be serviced. A service user wheelchair in the same house has also been serviced by the homes handyman who has been trained to do so. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 21 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): 32,33, 34, 35, 36 Staff turnover in some units has significantly impacted on the progress made by the home on achieving workforce targets within timescale and maintaining continuity for service users. The home has made good progress in ensuring recruitment practices are robust, but, improvements to reference checking will enhance this process. Little progress has been made by the home tom address shortfalls in the staff induction programme. Service users are benefiting from a happier, better-supported staff team. EVIDENCE: Owing to significant staff turnover in some of the units, the home has slipped in establishing a 50 qualified staff target for these units, since the last inspection, only 5 staff over all three units have NVQ 2 or above qualification. Staff rosters were viewed at inspection for all three units, discussion with staff indicated that apart from Mill house staffing levels had remained the same, owing to a change in dependency levels at Mill house following the departure of a service user, there was no longer a need for the higher staffing ratio previously in place, currently there are three staff to four service users, service users did not feel that the reduction in staff had impacted on their activities programme and staff spoken with felt the current levels were appropriate to the number and dependency of users. New staff files were viewed on the second day of inspection, whilst the inspector was satisfied that the home operates a thorough recruitment Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 22 procedure, and that staff files contained all relevant documentation required within the legislation, the inspector made a recommendation for improved vigilance around the content of references, and in one case this was discussed with the manager who will seek to clarify an anomaly in information provided, to ensure service users welfare is not placed at risk. Although the home has an induction programme a previous inspection highlighted concerns as to its content and implementation, the home were unable to demonstrate on this occasion that this outstanding requirement in respect of staff induction training has been addressed, the manager was reminded of the need to review this training in conjunction with the newly established common induction standards which become standard as from February 2006. A previous recommendation that LDAF training is routinely offered to staff new to learning disabilities is also still to be implemented. Staff’ have access to a general training programme covering mandatory core skills training and some more specialised training dependent on user needs. Training matrix are available. The home has until recently operated a qualification training programme for care staff who have been in post for six months, this is under review following changes to funding arrangements for this training from the government. Staff spoken with confirmed that supervision sessions are restarting following the departure of the previous team leader, whilst these were routinely undertaken the absence of the team leader caused some slippage in this area. Staff spoken with confirmed that previous anxieties in relation to communication around working patterns had been addressed and staff had been given an opportunity to express their views, and felt they had been listened to; staff are generally happy with the current shift pattern. Staff spoke very positively about the current management arrangements that have given them greater access to the Registered manager, and feel lines of communication are open, they feel listened to and some expressed the view that they now feel more confident in their role. Staff felt anxious that this new found improvement to communication was not lost by the insertion again of another layer of management, and the providers and the registered manager will need to take these views into consideration when finalising the management structure. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 23 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): 37,39,42, 43 Service users benefit from living in a well run well resourced home, where their health and safety is promoted. Systems for monitoring quality of provision and how user views influence and develop the service need to be implemented. Systems are in place to ensure the environment is maintained to a safe standard, shortfalls in staff induction training and recording practices in some areas could compromise user safety. EVIDENCE: The oversight of the units is undertaken by the registered manager, who has many years experience in a management role, has participated in continuous personal development and has attained the NVQ4 and RMA. The manager demonstrates a good understanding of development and resource issues for the site and has some influence in this area. The manager has regular meetings with the providers but would benefit from more formal recorded supervision arrangements. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 24 A number of self auditing and quality assurance measures have been developed and implemented in the main house, however, these are still to be extended to the smaller units and staff made familiar with them. Staff’ spoken with were unclear what quality assurance strategies are in place, although clearly forums for staff and users to express their views are occurring and minutes of user and staff meeting minutes were viewed at inspection. The home is still to evidence how engagement with all stakeholders and their views influence the development of the service. Analysis of user views is still to be published. It therefore, remains an outstanding requirement for the home to address these shortfalls. Servicing records for electricity and gas supplies, fire alarm systems and portable electrical appliances were viewed at inspection. Each unit retains its own fire book and records of fire alarm testing are being undertaken at specified intervals across all three units as the current alarm system is linked. The inspector has suggested that in order to ensure that recording of tests and checks are applied consistently it may be necessary to allocate one or two people specifically to this task. Emergency lighting and fire fighting equipments checks were not being routinely checked at monthly intervals in all units, records of fire drills contained staff who were no longer in post and new staff could not evidence from fire drill records that they had participated in a fire drill, it is a recommendation therefore that the home ensures that tests and checks of fire alarm systems are undertaken weekly with monthly checks of emergency lighting and fire fighting equipment checks, all care staff are to participate in a minimum of two fire drills annually, service users who participate must also be recorded as having done so. The home has made progress on addressing an outstanding recommendation in respect of a development plan for the service, whilst at present this takes a narrow view of service development focusing on environmental developments alone, following discussion with the manager at inspection it was agreed that this would be extended to reflect many of the other developments that are occurring or are planned within the service over the coming year or so. Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 25 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 3 3 X 3 X Standard No 22 23 Score 3 2 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 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Eastry Villas Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 3 DS0000048300.V257837.R01.S.doc Version 5.0 Page 26 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 YA20 Regulation 13(2) Requirement Handwritten changes to MAR sheets to be signed countersigned and dated. (Partially met within previous timescale of 30/8/05. Auditing of Mar sheets to reduce omissions in recording, medication errors to be recorded with actions taken to ensure safety of service users. The development of behaviour management guidelines is to be undertaken with the involvement of the care staff involved and the home to evidence their involvement. All staff to receive induction in keeping with common induction standards at commencement of employment, home to evidence this (not met within previous timescale 20/7/05) Home to implement and evidence quality assurance systems are in place to seek the views of users and stakeholders and how these influence service development. (Partially met within timescale 30/8/05) Timescale for action 31/12/05 2 YA23 13(6) 31/01/06 3 YA35 18(1) 31/12/05 4 YA39 24 31/01/06 Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 27 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 Refer to Standard YA2 Good Practice Recommendations CCD to improve liaison with respective units to ensure the views of staff are taken full account of in the selection process to ensure needs can be adequately met, and that the needs of existing service users are also considered. Locks should routinely be fitted to bedroom doors and users can then be offered the option to use or not, and their capacity to use appropriately assessed. The client care department to give equal if not greater consideration to the input of behavioural psychologists in the development of guidelines and strategies to minimise inappropriate behaviours. .Gore house to consider the upgrade of an upstairs bedroom which lacks stimulation and personalisation by the user (outstanding from previous inspection) Future developments and upgrade of the premises should involve the replacement of toilet facilities upstairs and downstairs; the current design could compromise infection control measures. (Partially addressed from previous inspection) Staff references to be thoroughly scrutinised and anomalies investigated. LDAF training to be offered to staff new to learning disability services. (Outstanding from previous inspection) Tests and checks of fire alarm and fire fighting equipment to be undertaking in keeping with stated timescales, and records of these checks maintained. Home to evidence that all care staff have participated in a minimum of two fire drills within a twelve-month period. 2 3 YA16 YA23 4 5 YA26 YA27 6 7 8 YA34 YA35 YA42 Eastry Villas DS0000048300.V257837.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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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