Inspection on 29/11/06 for Eldra Court

This inspection was carried out on 29th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eldra Court 22/08/07

Eldra Court 21/07/06

Eldra Court 07/02/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Eldra Court Eldra Court Third Drive Landscore Road Teignmouth Devon TQ14 9JT Lead Inspector Sam Sly Key Unannounced Inspection 29th November 2006 09:15 Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 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 Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 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. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eldra Court Address 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) Eldra Court Third Drive Landscore Road Teignmouth Devon TQ14 9JT 01626 868124 01626 868127 Education & Care (Devon) Limited Vacancy Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The bedroom on the ground floor next to the lounge must have an ensuite bath/shower room installed after the named resident vacates, and before the next resident is admitted. 21st July 2006 Date of last inspection Brief Description of the Service: Eldra Court provides a service for up to six residents with a learning disability. The Owners also provide a service for students with a learning disability at the two establishments that make up Oakwood College in Dawlish. The premises have disabled access and disabled toilet facilities on the ground floor. The ground floor comprises of a bedroom, lounge, a kitchen/diner leading outside onto a wide decked area, and the staff office/sleep-in room. The first floor is accessed by stairs and has a bathroom, four en-suite bedrooms and one bedroom without en-suite facilities. The house has parking to the front and enclosed gardens to the back. Eldra Court is within walking distance of the local shops and amenities, and only a short distance from bus and train routes. The weekly fee levels for Eldra Court are: £688.43 - £1561.62. Some staff, residents and relatives said that they had not seen the most recent Commission’s report for Eldra Court. The acting manager said he would make sure the report was available in the future. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. An unannounced visit took place at Eldra Court during a weekday in November. Hayley Hughes an Expert By Experience accompanied the Inspector. She and her supporter Gemma Brown spoke to residents. The staff on duty, and the acting manager Jarred Kenny were also spoken with. All types of written records were looked and a tour of all the shared rooms and some of the bedrooms was carried out. To write this report all the records of contact the Commission has had with Eldra Court since the last inspection were looked at. The acting manager provided information too. Four of the residents, five staff, four relatives, and one care manager returned comment cards to the Commission. All the standards that the Commission thinks are most important were looked at during the inspection process. What the service does well: What has improved since the last inspection? The acting manager has worked hard to make improvements to the service. One staff member commented that ‘things are gradually improving. We now Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 6 have new, enthusiastic staff’ ‘ I have faith in the new manager and he has worked very hard over the past few weeks to start improvements.’ Evidence was found to show that steps had been taken to meet all the outstanding requirements. 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. The summary of this inspection report can be made available in other formats on request. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 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 Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents understand their rights and responsibilities, but decision-making about moving to Eldra Court will be limited by a lack of clear specific information and procedures. EVIDENCE: There was one new resident living at Eldra Court. This resident was at College during the visit, so could not be asked their views on moving in. However, the acting manager had received a thorough assessment from the placing authority about the residents needs before admission. Four residents returned comment cards to the Commission which showed they were all asked if they wanted to move to Eldra Court, and they had all been given enough information to make the choice to move in. The acting manager had not yet developed an assessment format to be used by staff or an admissions procedure that was specific to Eldra Court, and residents had not been given contracts Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Decision-making is integral to resident’s lives at Eldra Court, however plans do not clearly identify how resident’s needs will be met. The procedures in place to manage resident’s money safely are not sufficient. EVIDENCE: Four resident’s care plans and risk assessments were looked at and the Inspector spoke with staff about how care plans were used. The Expert By Experience spoke to residents about what they did and looked at one resident’s plan. The acting manager said that the care plans for all the residents were being improved to make them more accessible with symbols and pictures. The Expert By Experience saw some of the accessible information to be used in the new plans and said ‘it was very good as long as it was set up for all residents files’. Each resident had a risk assessment, and one resident had a ‘traffic light system’, which gave detail of what staff should do if the resident became Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 10 upset. The Expert By Experience said ‘I thought this was good but maybe could be bigger and have pictures’. Pictures were used with this resident in their bedroom to help them understand what would be happening next in their day. Staff spoken with were not very sure about use of care plans, and did not demonstrate that they were useable documents. The Expert By Experience observed that one resident was behaving in ways that their care plan stated showed they were bored, however the Expert By Experience said ‘I didn’t see the staff taking notice of this and interacting with X.’ Also, the Expert By Experience said ‘I had been told X was on 1:1 [staff support] but I didn’t see much evidence of this.’ Two residents told the Expert By Experience that they had their own money and went shopping. There was information available about what benefits residents receive, however the system for accounting for residents finances still did not have a clear audit trail, and was not being monitored by the acting manager on a regular basis. Cash handled by staff was locked away safely. There was still no policy in place for dealing with resident’s money. Residents meet fortnightly to make decisions about what they are going to do, and are consulted on aspects of running Eldra Court. The acting manager is making improvements to the menu and activities information to enable residents to make clear choices in their lives. Staff were spoken with about their understanding of their role in promoting equality for residents. Staff had some understanding, and could give some examples of when they had challenged inequality but staff had not been provided with any training opportunities with regard to equality and diversity and no information was available at Eldra Court. Staff told the Expert By Experience that they were shortly going to start to learn Makaton so that they can better communicate with residents. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lead active, interesting lives at Eldra Court and in the wider community. Mealtimes are relaxed and enjoyed by residents. EVIDENCE: Each resident had a visual timetable to show what they were doing each day of the week. The acting manager had recently improved the range of activities on offer to residents, with their involvement, and was hoping to start these new activities soon. The Expert By Experience observed that what residents were doing during the visit was what was on their timetable. One resident was at College during the day of the visit and goes there five days a week. Residents told the Expert By Experience that they go swimming, go to the park and out for meals, and that many of them go back to their parent’s houses for Christmas. Residents also said they can go shopping, go to College to do pottery and cookery, and they have take-away at weekends. One resident Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 12 made a cake during the visit and the Expert By Experience said it was very tasty. The Expert By Experience was concerned that one resident was in their bedroom until lunchtime. The resident had missed their breakfast. The acting manager said this had happened before as the resident liked being on their own. This is not acceptable. The Expert By Experience was also concerned that the payphone in the hall was not private enough for personal calls. The acting manager said residents could use the office phone for private calls if they wanted to. Four residents returned comment cards to the Commission and said they always or usually made decisions about what they did each day. One resident said ‘I’d like to go out more at weekends especially on the bus.’ Another said they ‘really enjoyed the cinema.’ The Expert By Experience said ‘I do think the residents are given choices and have some control over their money and know about their medication.’ Four resident’s relatives returned comment cards to the Commission. All the relatives said they were made welcome at Eldra Court and could visit at any time. All four also said they were consulted about the care of their relative. One relative said ‘It is definitely home from home for the residents. Staff are like second parents, can’t praise them enough. What would we do without them!’ Three relatives were satisfied with the overall care provided, one relative was not and this matter had been taken up with the Owners through the complaints procedure. Meals were planned with residents during their fortnightly meetings. The visual menu board telling residents what meals they were having had not been kept up-to-date and there was some confusion amongst residents about what meals they were eating. The acting manager showed a new menu board that was being developed using photos of meals so that choice could be given to residents. All staff support residents to cook meals, and none of those spoken with had food hygiene certificates. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s personal and healthcare needs are met, and staff administer medication safely. EVIDENCE: Residents spoken with said staff were helpful when they went to the doctor, dentist and if they felt unhappy. All residents have a local doctor. Residents said they were happy with the way they are supported to look after their money, bathe and have their medication administered. The Expert By Experience observed one resident being included in the process of administering their medication. The staff have worked closely with the local learning disabilities team concerning one particular resident, and the resident’s plan now reflects the input of the professionals involved. There had been an incident reported to the Commission with regard to mistakes made about unfamiliar staff working with one resident, and this mistake was identified, investigated and put right by the Owners quickly. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 14 Resident’s medication is stored, administered and returns made to the Pharmacy appropriately. There had been two mistakes with the staff administration of medication reported to the Commission since the last Inspection. Both times the mistakes were identified, investigated and put right by the Owners quickly. The handwritten receipt of medication did not include the amount of medication received, and this meant medication stocks could not be audited. All staff receive training before they are able to give medication to residents. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff listen to residents concerns and act on them. Residents are protected from abuse. EVIDENCE: All the four residents that commented to the Commission knew who to go to if they were unhappy, and they named staff. These residents also all said that staff treated them well and listened to them. Eldra Court had a pictorial complaints procedure in plain English. Most of the relatives that commented to the Commission knew about the complaints procedure but the staff spoken with were not clear about the procedure, or where to find it. Residents were observed to approach staff and come in and out of the office to seek support from the acting manager throughout the visit. The Commission had not received any complaints about Eldra Court since the last Inspection, however the Owners had received a complaint that was being dealt with appropriately. There had been no adult protection issues identified at Eldra Court since the last Inspection. Staff spoken with knew what to do if they suspected abuse had taken place, and were about to attend adult protection training the following week. Other staff had already attended training. Neither a copy of Eldra Court’s adult protection policy nor a copy of the local authority Alerter’s Guidance could be found during the visit. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 16 Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Eldra Court is homely, well maintained and furnished and comfortable. Systems are in place to keep it this way. EVIDENCE: The Expert By Experience observed that Eldra Court was ‘homely with a relaxed atmosphere and was clean and tidy’ with lots of games and DVD’s in the lounge. The sofas in the lounge were torn and uncomfortable though. The environment at Eldra Court was also bright and well maintained with resident’s bedrooms reflecting their personalities and hobbies. Residents who returned comment cards to the Commission said that the environment was always clean and fresh. One resident said ‘ I help to keep the house clean’, and all residents are encouraged to help around the house and do their own laundry and cleaning. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 18 The ground floor at Eldra Court is accessible to wheel chair users, with a ramped access and an accessible toilet, however there are only stairs to the first floor. Neither the fire service nor the environmental health department have re-visited since the Home was registered in September 2005. Staff said maintenance issues are dealt with reasonably quickly. A cleaning programme was now in place to ensure all parts of the house receive regular attention. Laundry facilities were sufficient to protect everyone from crossinfection. However, staff are still waiting to do training on infection control. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An enthusiastic staff team support residents, however they are not yet receiving the necessary recruitment checks, supervision and training to work effectively. EVIDENCE: Five staff returned comment cards to the Commission and two of the staff on duty and the acting manager were spoken with during the visit. Comments from staff showed that the team had been through a lot of change since the last Inspection, with the previous registered manager and several staff leaving, other new staff starting. Staff recognised this had an effect on the team and on residents, for whom it has been ‘rather unsettling’. One resident commented to the Commission that they missed the previous manager and named staff. Staff comments and a comment from a relative showed that ‘things are gradually improving’ and ‘positive changes have been made recently and that these will take time to have an effect on residents.’ Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 20 The staffing numbers reflected in the rotas provided showed that staffing levels were sufficient to meet the needs of the residents at Eldra Court, unfortunately on the day of the visit one staff member was missing, thereby reducing the number of staff on duty. The Expert By Experience said that she did not see much evidence of the 1:1 support she had been told that one resident needed. The acting manager said that he was aware some training was required with staff to ensure they knew what they should be doing when supporting this resident. One relative who returned a comment card to the Commission said they had concerns about the lack of specialist training provided to staff although the ‘caring element [of staff] is not in question’. Staff had been working with a resident with specialist needs for many months without training, however training had now been provided the week before the visit. There was a training plan for the staff team however, it required up dating, as it was not clear that training required had been booked. The staff spoken with required a range of health and safety training as well as specialist training. Both staff spoken with were keen to do any training offered. The staff spoken with said they had not undertaken induction training when they started, however the acting manager showed an induction programme that had recently been given to all staff and would be started shortly. Staff spoken with were enthusiastic, approachable and showed a genuine interested in the welfare of residents at Eldra Court. Three staff files were examined and found to include job descriptions, contracts, application forms, interview forms and POVA First (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) checks. None of the three files contained the required two references. A representative of the Owner showed a newly written policy that, when used shortly, would make sure that these shortfalls would not happen again. The acting manager had not had supervision sessions with staff since the last Inspection in July 2006, although the staff had regular staff meetings, and one staff member had received an appraisal of their work. When asked what could improve the service at Eldra Court staff said ‘more structure as to what staff does what on each shift.’ The acting manager said he was aware of this problem and was solving it through the new activities programmes that have been developed for residents. Another comment was ‘to all work as a team.’ Staff spoken with at the visit said they thought this was happening more now. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Currently, Eldra Court does not have a registered manager or a robust Quality Assurance system to monitor and improve the service. EVIDENCE: The registered manager had left Eldra Court since the last Inspection, and an acting manager is in place. This acting manager is to be put forward to the Commission to be registered. The acting manager has put in a lot of effort to improve the problems identified at the previous Inspection, and this effort was commented on by relatives and staff who returned comment cards to the Commission. All staff who returned comment cards to the Commission said that they felt supported by the acting manager, and one staff member said ‘I have faith in Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 22 the new manager, he has worked hard over the last few weeks to start improvements.’ The acting manager had not yet been given a job description nor had he received any formal supervision. One relative who commented to the Commission had ‘major concerns’ about the ‘poor communication at all levels’ at Eldra Court. These concerns have been shared with the Owners using the complaints procedure. The system in place for monitoring and improving the quality of the service at Eldra Court is still not sufficient, and although questionnaires have now been sent to residents and relatives, the system does not yet identify and put into place a plan to improve the service. Also the Owners are not yet monitoring Eldra Court on a monthly basis as is required. Despite several recommendations at the pervious two Inspections there is still not a comprehensive range of policies and procedures for staff to follow. Staff training has been audited and a training plan including health & safety training put in place, some of this training has not yet been arranged though. The required fire checks are taking place and accidents and incidents are being duly recorded. There is not an easily accessible file of all these checks kept in the home though. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 23 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 3 3 X 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 2 X 3 X Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 15 Requirement The registered person must prepare a written care plan for each resident. (Timescale 10/03/06 & 1/10/06 - not met) Unnecessary risks to the health and safety of residents must be identified. (Each resident must have a detailed risk assessment) (Timescale 10/03/06 & 1/10/06not met) The registered person must make arrangements for the recording of medication. (Handwritten records must include the quantity of tablets received) Two written references must be obtained for staff before employment. A manager must be registered with the Commission. The registered person must visit the home monthly to report on the conduct. A copy of the report must be sent to the Commission. The registered person must establish and maintain a system for reviewing and improving the quality of care at Eldra Court. DS0000064403.V313061.R01.S.doc Timescale for action 28/02/07 2. YA9 13(4) 28/02/07 3. YA20 13 (2) 06/12/06 4. 5. 6. YA34 YA37 YA39 19 Sch.2 8 26 30/12/06 06/01/07 06/01/07 7. YA39 24 28/02/07 Eldra Court Version 5.2 Page 25 (Timescale 10/06/06 & 01/10/06 - not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA2 YA4 YA5 YA7 Good Practice Recommendations Eldra Court should have an assessment format and procedure. Eldra Court should have a comprehensive admissions procedure specific to the Home. Each resident should have a signed and agreed contract. Each resident should have clear auditable accounts of their finances, with information available of what benefits they are receiving. Staff should have a good understanding of equality and diversity issues. All staff that support residents with cooking should have food hygiene certificates. If residents spend a lot of time in their bedrooms, plans should be in place to check on them regularly and ensure they do not miss meals. Eldra Court should have a policy about residents finances including detailing what support staff will offer, that agreement will be obtained from the resident or their representative, and how records will be kept. There should be a copy of the Home’s adult protection policy and the Alerter’s Guidance available for staff at Eldra Court. The worn sofas in the lounge should be replaced. All staff should have an induction soon after employment and suitable training and support throughout their first year and beyond. There should be an up-to-date training plan for staff. Regular staff supervision should take place. The acting manager should have a job description and regular supervision. All the required policies and procedures should be in place. These policies and procedures should be specific to Eldra Court. DS0000064403.V313061.R01.S.doc Version 5.2 Page 26 5. 6. 7. YA17 YA17 YA23 YA12 YA7 YA23 YA24 YA35 8. 9. 10. 11. 12. 13. YA36 YA37 YA40 Eldra Court 14. YA42 A file should be kept in the home of all the health and safety checks that take place regularly. Eldra Court DS0000064403.V313061.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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