Inspection on 22/02/06 for Eight Ash Court

This inspection was carried out on 22nd February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 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 13/10/05

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 Tim Thornton-Jones Unannounced Inspection 22nd February 2006 10:00 Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 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.V283880.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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 13th October 2005 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 three 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, none have en-suite facilities. Each of the two units have separate 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. The service ‘pre-existed’ and therefore the standards associated with the premises comply on this basis only. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As a result of this inspection all National Minimum Standards, with the exception of one (NMS 43), have been reviewed within the inspection year concluding 31st March 2006. The outcomes of both these inspections indicate that the overall practice and standard of care to service users and the support of staff have improved. The appointment of Mrs J Kennedy as Manager has made a significant influence in this process. This inspection showed that the two shortfalls highlighted at the previous inspection had been resolved. Two further shortfalls have been identified, both of which are the principle responsibility of the Person in Control. Overall, the standard of care and professional practice is good, with some areas having potential to further develop. What the service does well: What has improved since the last inspection? 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. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 6 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.V283880.R01.S.doc Version 5.1 Page 7 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): 3, 4 & 5 • Service users benefit from the home’s capacity to meet their needs and have opportunity to sample the home before making a commitment to live there. Each person is provided with terms and conditions. EVIDENCE: No service users have been admitted to the service during the period since the previous inspection, however, based upon the findings of this inspection the service was found to be operating in a manner that would enable prospective service users to be informed about the way in which the home would meet their needs and aspirations. The service has an admission procedure that includes the receipt of a needs assessment undertaken by the ‘care manager’ who would be responsible for the planned move of the prospective service user. In addition, the service would complete an internal information gathering process to assist with the formation of an initial plan of care. Consultation with the service user and their family/advocates forms part of this process. The service provides a 3 month trial period for both the home and the service user to decide how successful the arrangement has been and to decide if the person is to remain living at the home. At the point of confirming that the person is to continue at the home a terms and conditions of residence are completed, this forms part of the service users guide. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 10 • Service users benefit from care planning, support and assistance to participate in the day-to-day aspects of the home and have their confidentiality maintained. EVIDENCE: This inspection was able to establish, via observation of practice, available documentation and discussion with staff and service users, that the regime and ethos of the home reflects an open and transparent way of working. Service users and staff appear more confident and the Manager expressed a clear view and understanding of a person-centred approach to care delivery. Service users are consulted more about the way the home operates, particularly regarding leisure and social activities. The Manager explained the part that service users play in deciding how staff are recruited, which enables service users to express their views about their first impressions of prospective carers. Care plans were examined at the previous inspection and were found to comply with National Minimum Standards, however, one care plan was again Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 9 reviewed as the development of practice had further changed since the previous visit. The sample showed that care strategies had improved, with all of the main parts of the care planning process being in place. Decision making was based upon assessment, both formal and informal, and in consultation with the service user. The decisions were appropriate to the needs of the person and clear methods were identified to enable staff to carry out the actions. Ongoing recording had improved within the sample taken, although the Manager acknowledged that recording and report writing is an ongoing area of practice development for staff. Healthcare issues were not examined on this occasion. Care reviews were evident and a key worker system was in operation. Service users attend a variety of activities based upon occupational, social and recreational pursuits. These were reflected within the care plan. The arrangements for the protection of information and confidentiality were sound, with security arrangements in place. Sensitive information is maintained in locked cabinets. The Manager demonstrated a good understanding of the principles and practices associated with the maintenance of records and the way in which information needs to be managed. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 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): 11 & 14. • Service users have opportunities for personal development and engage in appropriate leisure activities. EVIDENCE: Service users are encouraged to be as self-supporting as possible, both within the home and the wider community, with support from staff. This approach is reflected within the plan of care. The communication observed between service users and staff was appropriate in terms of language, tone, volume and content. The content was observed to be supportive and encouraging, in a way that was reflective of appropriate age related topics, although this is a challenging area of practice, particularly in relation to external influences. Activities range from regular day activity commitments and further education class attendance to more leisurely activities using the local facilities. These were well documented. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 11 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): 19 & 20 • Service users’ physical and emotional needs are met and arrangements for the administration of medicines were satisfactory. EVIDENCE: The care planning approach takes account of service users’ general healthcare needs by monitoring primary healthcare, such as GP visits and optician and dentist for example. Some service users require support from more specialist healthcare and the arrangements were discussed with the Manager. The arrangements in place are reflective of ‘ordinary life’ principles, as far as practicable, with service users attending appointments arranged within the community. The security and administration of prescribed medicines were not fully reviewed, although the arrangements appear to be satisfactory. The practice was not directly observed although the practice was reviewed with the Manager, who demonstrated a good understanding of the principles and practice required to ensure safe administration. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 12 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): The arrangements were not examined in detail. EVIDENCE: The Manager confirmed that no complaints had been investigated by the home during the period since the previous inspection. One previous Protection of Vulnerable Adults (POVA) issue had now been resolved. The Manager demonstrated a good understanding of POVA issues and clear procedures were in place. The Manager expressed that the previous POVA matter was a steep learning experience and she considered that the matter had positively influenced her further understanding and practice of the issues. The CSCI considers that the matter was well managed. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 13 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): 25, 26, 28 & 29. • The environment is maintained in a homely and comfortable manner, taking account of service users’ privacy and comfort. EVIDENCE: The visit included a tour of one of the two dwellings on site and, whilst not all of the bedrooms were visited, all communal rooms including toilets and bathrooms were viewed. Of the bedrooms visited, all were individual and well furnished with appropriate fittings to meet the needs and preferences of the occupant. All had appropriate levels of furniture and fittings/equipment. Some aspects of the communal facilities had been redecorated and improved since the previous visit. The home throughout was clean and well decorated having a homely and comfortable atmosphere. The external grounds are well maintained. The front of the dwellings are laid to hard standing for vehicular use. Access to and from the dwellings is wheelchair friendly. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 14 The adaptations and equipment were noted to be well maintained and appropriate to meet the needs of those who are not fully mobile. The overall arrangements continue to be well maintained. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 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): 31 & 33 • Service users benefit from clarity of staff roles and responsibilities, and the support of an effective staff team. EVIDENCE: The inspection concluded that staff were continuing to work in a positive way and as ‘a team’ and this is an approach the Manager has paid particular attention to over the previous few months. Staff are aware of their responsibilities individually, for example as key workers, and as a whole team in relation to working harmoniously. Staff had reported that the way in which the home is managed and now operates is clearer, with more emphasis on meeting service users needs and preferences. Staff training and development were examined and a sample of four carers’ records were considered. All four were working toward a Learning Disability Framework Award (LDAF) qualification and all had been trained in First Aid and Food Hygiene. This latter training is important as the service does not employ separate cooks. Of the senior staff, all had received training in the administration of prescribed medicines. Three of the four had received POVA training. Not all staff had received training in caring for people who have Epilepsy. This should be a priority since Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 16 the home accommodates service users who require this care. It is recommended to ensure that each shift/duty has a carer who has received training in Epilepsy, where possible. Of the sample four staff, two had completed NVQ training and two were working toward the qualification. Overall, the commitment to staff training and development was well organised and progressive. The staff/service user ratios have been calculated using a method recommended by the Department of Health. This indicated that a total of 548.84 hours were required to provide personal care for service users per week. The staff roster indicated that 664.75 were being deployed leaving a variation of about 116 hours per week to accommodate support tasks such as cooking and cleaning etc. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 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, 38, 39, 40 & 41 • Service users benefit from a well run home with a positive ethos, leadership and management approach. • • Quality assurance systems need to be further developed. Some record keeping will need to be improved to meet National Minimum Standards, although policies and procedures are well developed. EVIDENCE: The Manager, Mrs Kennedy, has developed the management of the home since her commencement and has resolved the two shortfalls highlighted as a result of the previous inspection. Mrs Kennedy is now registered with CSCI having been confirmed as ‘fit’ to manage the home under the meaning of the Care Standards Act 2000. This inspection concludes that she has made a positive contribution to the leadership of the service. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 18 The quality assurance and quality monitoring was reviewed and the service has developed a consultation process with service users and their supporters, which is positive. It is important, however, to ensure that the service is clear about how it intends to measure outcomes and to define what is acceptable by the organisation in terms of quality. The approach needs to be refined, in that clear statements of quality need to be made and these then tested by consulting with service users in a suitable format and by appropriate methods. The results then need to be analysed to determine to what extent the intended quality standards have been achieved. Where the results fall below the stated quality objectives, a clear plan needs to be formulated to show how the service will meet the stated quality objectives. An annual report of this process then needs to be copied to CSCI. Policies and procedures were sampled and, of these, all were satisfactory and reflective of the service outcomes. Various records were sampled at this visit and the majority were satisfactory. The Manager will need to ensure that the staff roster is validated as an accurate record. This was discussed. The monthly ‘Person in Control’ reports have not been regularly sent to the home for the Manager’s use or to CSCI and this must be maintained in accordance with Regulation 26 of the Care Homes Regulations 2001. Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 3 26 3 27 X 28 3 29 3 30 X STAFFING Standard No Score 31 3 32 X 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X 3 3 X 2 3 2 X X Eight Ash Court DS0000017809.V283880.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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 YA39 Regulation 24 Timescale for action The Registered Person must 30/06/06 ensure that a system is in place and is maintained to review and improve the quality of care provided at the home. The Registered Person must 30/04/06 ensure that all records are suitably maintained and reports submitted. Requirement 2. YA41 17 26(2 to 5) 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 It is recommended to ensure that, where staff are not trained in an essential skill, at least one staff member is on duty to ensure appropriate support. 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