Inspection on 13/10/05 for Eight Ash Court

This inspection was carried out on 13th October 2005.

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

The inspector found 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eight Ash Court 28/11/06

Eight Ash Court 22/02/06

Eight Ash Court 01/03/05

Eight Ash Court 07/09/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Eight Ash Court Halstead Road Eight Ash Green Colchester Essex CO6 3QJ Lead Inspector Steve Boyd Final Unannounced Inspection 13th October 09:30 Eight Ash Court DS0000017809.V252847.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 Eight Ash Court DS0000017809.V252847.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. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eight Ash Court Address Halstead Road Eight Ash Green Colchester Essex CO6 3QJ 01206 710366 01206 710366 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) Mr Pelandapatirage Gemunu Susantha Dias Mrs T Cheung, Mr W K Cheung Mrs Jacqueline Kennedy Care Home 12 Category(ies) of Learning disability (12), Physical disability (3) registration, with number of places Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 12 persons) Two named persons, under the age of 65 years, who require care by reason of a learning disability, who also have a physical disability, who have resided in the home since April 2002 One male person, under the age of 65 years, who requires care by reason of a learning disability, who also has a physical disability, whose name was made known to the Commission in June 2003 The total number of service users accommodated in the home must not exceed 12 persons 1st March 2005 3. 4. Date of last inspection Brief Description of the Service: Eight Ash Court is a care home providing personal care and accommodation for twelve individuals with learning disabilities of whom four named individuals have physical disabilities. It is owned by Mr R Dias and Mr & Mrs Cheung. The home is located in Eight Ash Green within a walking distance from local amenities. All of the home’s rooms are single and none have en-suite facilities. Each of the two units have their own kitchen, laundry and communal areas. The care home was registered prior to the commencement of the Care Standards Act 2000 and the requirements of the National Minimum Standards. On this basis the service ‘pre-existed’ and therefore the standards associated with the premises comply on this basis only. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during one day in October 2005. During the inspection two service users were spoken with and also one relative of a service user was spoken with on the telephone. The inspector had discussions with three care staff members and was assisted throughout the inspection by the manager, Mrs Jacqui Kennedy. As well as the above, the inspector toured the premises and reviewed various documents and policies. Of the twenty-four standards assessed during the inspection, twenty-two were found to be met and two partially met. What the service does well: What has improved since the last inspection? What they could do better: An examination of the staff rota indicated that some staff are working in excess of 50 hours per week in order to maintain appropriate staff levels. Although the hours worked by some staff are voluntary, the long hours could be detrimental to both staff and service users’ welfare and therefore the practice needs to change. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 6 Service users’ contracts still required some work to make them in line with National Minimum Standard requirements, i.e. the registration authority was still shown as being Essex County Council rather then Commission for Social Care Inspection. 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. Eight Ash Court DS0000017809.V252847.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 Eight Ash Court DS0000017809.V252847.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 & 5 Suitable information for prospective service users was available. Prospective service users needs and aspirations would be assessed prior to admission. An amendment to the contract still needed to be made for each service user. EVIDENCE: Since the previous inspection the home had changed the Statement of Purpose, to reflect the requirements of National Minimum Standard number 1, by including specific details of the premises and room sizes. The home has not admitted any new service users since the previous inspection. An assessment by a social care professional, which was not available for one service user at the previous inspection, had been made available by the time of this inspection. The manager was aware of the need to ensure any service users admitted to the home in the future had assessments, completed prior to admission. Although each service user had an individual written contract with the home, the registration authority was still detailed as being Essex County Council rather than the Commission for Social Care Inspection. The manager undertook to ensure that this was changed. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Service users’ needs and personal goals were reflected in individual plans of care. Risk assessment was undertaken on all service users. EVIDENCE: At the previous inspection not all service users had an allocated key worker, as a means of providing an individualised care service. This had been rectified at the time of this inspection. Service users’ care plans were sampled and these were seen to be based on the activities of daily living, with objectives set and review dates pencilled in periodically. Service users, likes and dislikes were recorded and daily reports indicated what service users did and achieved on a daily basis. Risk assessments available, regarding service users have been reviewed by the new manager, Mrs Kennedy, and were now signed and dated. The assessments covered risks both within and outside of the home and had clear strategies on how risks could be minimised. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Service users were found to be able to take part in appropriate activities for their age and interests. The service users utilised the facilities of the local community and had appropriate personal and family relationships. Services users’ rights and responsibilities were respected and recognised. Service users enjoyed the food on offer at Eight Ash Court. EVIDENCE: Service users were found to be involved in a number of activities, which they enjoyed, such as attending a Gateway club, making trips to the local pub, going to day centres, trampolining and swimming sessions. Many of these activities take place in the local community, or in the wider community of Colchester. All service users were found to have degrees of contact with family and friends. One service user’s relative, spoken to during the inspection, stated she was “most impressed with the home”, and that her relative “gets to do the things she likes”. Relatives are able to visit the home when they like and a number of service users also visit the homes of their relatives. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 11 The manager advised that she is intending to review the menus currently available at the home, with a view to offering more choice. The likes and dislikes of service users were recorded and any special requirements for food documented. Service users spoken with during the inspection indicated they were happy with the quality and quantity of food on offer. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20 Service users received personal support in a manner appropriate to them. The home’s medicine administrations system was in line with requirements. EVIDENCE: Service user’s spoken with during the inspection said they were well treated and cared for by staff. Care plans indicated how personal support should be given. The relative of a service user, spoken with during the inspection, stated that her relative was “extremely well cared for”. The home operates a monitored dosage system of medicine administration. Service users, at the current time, either choose not to or are unable to selfadminister medication. The medicine administration system was seen in Bungalow 2 and was found to be operating appropriately. Staff who administer medication have received appropriate training. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Service users’ views are listened to and acted upon, where nessecary. Policies and procedures indicated service users are protected from abuse, neglect and self-harm. EVIDENCE: The home had not received any complaints since the previous inspection in March 2005. An appropriate complaints procedure was seen to be available for service users or their relatives/representatives. There had been no Protection of Vulnerable Adult (PoVA) issues referred or investigated since the previous inspection. The home had appropriate policies and procedures to follow should a PoVA matter arise. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30 During the inspection service users were found to live in a homely, comfortable and safe environment. Bathroom facilities were seen to offer privacy and be appropriate to individual service user needs. The two bungalows were found to be clean and hygienic. EVIDENCE: Service users’ rooms and communal facilities were seen to be well decorated and contained plenty of evidence of their own individual interests and tastes, by way of photographs, posters, music equipment, televisions etc. There were no safety hazards seen during the inspection. The bungalows were found to be clean and without any offensive odours permeating the buildings. Since the previous inspection, both of the bathrooms in the two bungalows had new shower units installed to give greater ease of use for those service users with some physical disabilities. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 15 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 Service users benefit from competent and qualified staff. The staff team’s effectiveness could be compromised by a number of staff working long hours. The recruitment policies and practices of the home support and protect service users. Service users’ needs were being met by appropriately trained staff. EVIDENCE: Staff spoken with during the inspection presented as personable and competent. At the time of the inspection, seven of the current seventeen care staff had achieved National Vocational Qualification at Level 2 or above and the home would of passed the fifty percent mark within six months of the inspection. A number of staff have completed Learning Disability Award Framework training. Although the staffing rota indicated that the level of staff on each bungalow met the requirements and needs of service users, this was sometimes done by some staff working hours in excess of fifty per week. The manager understood that this was undesirable and needed to change as soon as possible, either by recruiting new staff or the use of agency staff. The recruitment process for staff included the completion of application forms, interviews taking place, references being taken up, Criminal Record Bureau checks undertaken and proof of identity being obtained. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 16 The inspector saw evidence of various training certificates for staff on their files, for example moving and handling certificates, first aid certificates, epilepsy training certificates, as well as the National Vocation Qualification training undertaken by many staff. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Service users were benefiting from a well run home. The home undertakes self-monitoring and review, involving service users and their relatives/representatives. Service users’ health, safety and welfare is promoted and protected. EVIDENCE: The home’s newly registered manager, Mrs Kennedy, was found by the inspector to have a professional and energetic approach to managing the home. Staff spoken with during the inspection were clearly happy with the support they received from the manager, one describing her as “brilliant”. The home has a quality assurance monitoring and review system. A new cycle of seeking service users’ views was due to begin in January 2006. The manager indicated she might make some of the presentation of the information easier to read in the future. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 18 The inspector noted no health and safety issues during the inspection. Safety certificates were seen for gas, electricity, legionellas disease, fire equipment etc. A number of staff had completed first aid training. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 19 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 X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 2 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Eight Ash Court Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000017809.V252847.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 5 Requirement The registered person must ensure that contracts of residence for service users contain all required information. The registered person must ensure that staff do not work excessive hours, which could be detrimental to themselves and service users. A timescale for action must be sent to the CSCI. Timescale for action 31/12/05 2. YA33 17 30/11/05 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. Refer to Standard YA32 Good Practice Recommendations The registered person is recommended to ensure that at least 50 of care staff obtain an NVQ at Level 2 or above by April 2006. Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Eight Ash Court DS0000017809.V252847.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!