Inspection on 07/02/06 for Eldra Court

This inspection was carried out on 7th 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 6 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 29/11/06

Eldra Court 21/07/06

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 Announced Inspection 7th February 2006 9.45 Eldra Court DS0000064403.V270451.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 Eldra Court DS0000064403.V270451.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. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 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 Mr Marcus Richard Lear Comyns Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Mr Marcus Comyns to complete NVQ 4 and the relevant Registered Manager Award components before September 30th 2007. 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. N/A Date of last inspection Brief Description of the Service: Eldra Court cares for up to six residents with a learning disability. The Owners also provide care for students with a learning disability at the three 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. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Inspection of Eldra Court since it was registered last year. The registered manager Marcus Comyns and the responsible individual Frank Loft were present at the visit. Evidence was collected by speaking to all five residents, discussion with staff on duty, and discussion with Marcus and Frank. Care, health and safety and staff records were examined and a tour of the building was made. The Commission also received comment cards from all five residents and three relatives. What the service does well: What has improved since the last inspection? What they could do better: Although staff are very aware of the present residents needs, the registered manager needs to make sure the Home has a robust assessment and risk assessment format, and that each resident has a detailed care plan. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 6 To keep the environment at Eldra at the high standard it currently is, a written maintenance and renewal programme is required. To ensure staff have all the training they need to meet resident’s needs a staff team training plan is required, and to ensure the quality of services proved at Eldra Court remains high a Quality Assurance system is required. A number of best practice recommendations are also made at the end of this report. 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. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 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.V270451.R01.S.doc Version 5.1 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): 2, 4 & 5 Current resident’s needs are well understood, however to ensure this is the same for new residents an assessment format is required. To ensure residents understand their rights and responsibilities, and have the opportunity to make a choice about moving to Eldra Court clear information and procedures are required. EVIDENCE: All the resident, some of the staff and the registered manager came to Eldra Court from Oakwood College, where the residents needs had been well assessed and understood over a two or three year period. This has meant that Eldra Court has not yet developed it’s own assessment format and procedure. The registered manager has also not yet developed an admissions procedure, but the next planned admission is not until July 2006. All the residents at Eldra were very involved in their move. They chose furniture and fittings, and their bedrooms were painted as they wished. The registered manager is working on developing a contract for residents, as there is no format in place. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 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, 7 & 9 Decision-making is integral to resident’s lives at Eldra Court. To ensure staff are able to support residents to meet their goals, and have as independent lives as possible, care plans and risk assessments are required. EVIDENCE: The registered manager demonstrated that work had started on developing a detailed care plan for each resident. The format was discussed and the registered manager agreed to go ahead and complete a plan for each resident as a priority. A risk assessment had been developed for each resident with regard to the environment at Eldra Court. The registered manager agreed to go ahead and expand these risk assessments to develop a format for use with residents at Eldra Court. The registered manager and staff have worked hard to include residents in decision-making at Eldra Court. Resident’s have House meetings regularly, and have support from individual staff when making decisions about what they want to do. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 10 Resident’s finances were discussed, and it was found that records were kept of resident’s money, and money handled by the Owners in their corporate appointee capacity. It was recommended however that Eldra Court develop a policy about resident’s finances detailing how staff are going to support residents to manage their own finances. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Residents lead active, interesting, stimulating lives at Eldra Court and in the wider community. The mealtimes are relaxed and meals are tasty and nutritious. EVIDENCE: On the day of Inspection one resident went into town for a haircut and a coffee, and the others went horse riding. Resident’s obviously enjoyed these activities as they chatted happily about them over lunch. In the afternoon residents were decorating mugs in their art and craft session. Residents had linked into educational classes at the local College, and used the local leisure facilities. Each resident had a weekly activity programme based around what they enjoyed. This included a communication group, cookery, riding, music, helping with the household tasks, playing football, doing kick boxing, trips out to local attractions, walks, swimming, bowling and visiting friends. The residents had been to lots of shows and pantomimes over the Christmas period, and were starting to plan their annual holidays. Eldra Court has a vehicle that residents can use if they do not use public transport like the train or bus. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 12 The registered manager was developing a picture based communication aide that would help residents make choices about what they wanted to do, and where they wanted to go. Staff are enthusiastic and are using their skills to offer cookery and art and craft. They have also spent time finding out what is available in the community and making sure residents can access a range of activities. The registered manager said he was considering ways of developing neighbourly relationships with the community now residents were settled. Residents have a lot of contact with their families, some residents spend holidays with parents, and others stay in touch by phone, e-mail and visits. The registered manager had just bought a web-cam to enable parents and residents to keep in touch. Residents have single bedrooms, with keys provided; some residents are still getting used to using their keys. During the whole inspection staff were actively interacting with residents. A meal was shared with the residents and staff, which was relaxed and tasty. Residents discuss what they want to eat, and help to buy, prepare and clear away after a meal. Residents said they liked the meals at Eldra Court. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Resident’s personal and healthcare needs were met, and staff administered medication safely. EVIDENCE: Resident’s said they liked the way staff help them. Personal care is provided privately and the registered manager is developing detailed care plans guiding staff on how residents should be supported. Staff also help residents choose clothes. One resident was taken to the hairdresser on the day of Inspection. Healthcare is closely monitored, and there was examples of professional advise having been sort for residents since the home opened. Residents are all registered with a local GP, and have regular chiropody and dental checks. Staff were completing a distance learning medication course, and some had received medication training at their previous post at Oakwood College. Medication was kept in a secure metal cabinet and there was evidence that medication was received, and administered appropriately. There had been no returns yet. The local pharmacist had visited and been happy with the procedures in place. Staff had access to information on the drugs that were being prescribed. Residents had regular drug reviews. Residents had given their consent to have medication administered by staff. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staff listen to student concerns and act on them, and students are protected from abuse. EVIDENCE: Residents are given lots of opportunities to discuss issues with staff, during formal meetings, and 1:1 meetings. Residents said they felt able to talk to staff if they had a concern. There was also a written complaints procedure, which included symbols and the registered manager was making sure the format was not too complex and was fully understood by residents. The Commission had not received any complaints about Eldra Court. The responsible individual Frank Loft informed the Commission he had very recently received a complaint, and provided evidence that he was dealing with it appropriately. The registered manager had developed an adult protection policy, which was discussed and added to, there was also a copy of the Local Authority Alerter’s Guidance available for staff. Staff spoken to said they would inform the registered manager immediately if they suspected abuse. The registered manager said that four staff had previously done adult protection training and positive behavioural intervention, and he was in the process of finding training for the rest. The registered manager was attending a course in the near future. It was recommended that the registered manager develop robust policies regarding the protection of resident’s money and financial affairs. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Eldra Court is homely, comfortable, clean and hygienic, however to remain so on a long-term basis, a written maintenance and renewal programme must be adhered to. EVIDENCE: Eldra Court had only been registered a few months and the environment was clean, bright, homely, well maintained and newly furnished. Each resident had their own single bedroom and four residents had their own en-suite facilities. To register with the Commission, the responsible individual had ensured that the fire protection systems were of a standard agreed by the Fire Service, and the food hygiene practices and kitchen environment were to a standard agreed by the Environmental Health Department. It was agreed that to maintain the high quality of the environment maintenance and renewal programme, with timescales for acting on deficits, kept at the home was required. Eldra Court has ramped access and a toilet accessible to a wheelchair user. The laundry facilities were clean, accessible to residents and hygienic. The kitchen facilities were clean, however it was recommended that to ensure the kitchen facilities remained hygienic a written cleaning plan, including a regular deep clean be adhered to. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 16 Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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 A fit, competent effective staff team supports residents, and to ensure staff have the appropriate training there must be a team training plan. EVIDENCE: Rota’s and staff discussion provided evidence that there are enough staff on to meet the needs of residents, which includes personal care needs and taking them out to activities in the community. Staff spoken to were enthusiastic, interested, motivated and approachable to residents. Staff had a range of skills, and were aware of what training they required to do their jobs well. Staff felt supported by the registered manager, and felt he was approachable. Staff felt they could contribute ideas about how to better meet the needs of residents, and that these ideas were welcomed. Residents said staff were ‘nice’. ‘kind’, and ‘good fun’. Comments from resident’s relatives said staff are ‘always available to talk to and are kind and caring’. Discussion with the registered manager found that a staff training plan and staff training and development files were being developed with the responsible individual. One staff member had NVQ 2, and the registered manager had plans to get the other staff on appropriate training programmes. The registered manager had supervised each staff member once since the Home began, and it was recommended that to ensure this did not slip future supervision dates were diarised in. Staff had begun to identify training needs Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 18 in these supervision sessions. There had been staff meetings, which staff said they felt able to contribute to, and that the registered manager listened to their views. Policies were beginning to be discussed with staff at team meetings. It was recommended that staff meetings were recorded. Four staff files were examined and found to hold all the appropriate checks, identification and employment history. The responsible individual was in the process of developing a staff interview format to record decision-making during interview. Staff had all been given, and had discussed with the registered manager the General Social Care Council code of conduct. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 40 & 42 The registered manager is putting into place the systems and procedures necessary to ensure residents benefit from a well run home. EVIDENCE: The registered manager has now been in post for a few months and is continuing with his management training. There was evidence that he had spent a considerable amount of time developing the systems and procedures necessary to run Eldra Court. There was still a little way to go before this was fully achieved. Eldra Court had some quality monitoring procedures in place, but the registered manager and responsible individual had not yet developed a Quality Assurance system that both monitored and improved the services provided and involved residents and other interested parties. The registered manager was in the process of auditing the staff training requirements so that every staff member had attended mandatory health and safety training in manual handling, first aid, food hygiene and infection control. The fire checks and fire training was up to date and accidents were being Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 20 recorded, and incidents were dealt with appropriately. The wiring in the home had been checked before registration, as had the heating and electrical systems. The responsible individual said that the water was being tested for Legionella in the next few days, and the environment was regularly risk assessed. It was agreed that a file would be kept at Eldra Court, which held written evidence of when environmental checks occurred. The registered manager was in the process of writing all the necessary policies and procedures for Eldra Court. Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 3 X 3 X 2 2 X 3 X Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 22 NO 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 2 3 4 Standard YA2 YA6 YA9 YA24 Regulation 14 15 13(4) 23 Requirement Eldra Court must have an assessment format and procedure. Each resident must have a detailed care plan. Each resident must have a detailed risk assessment. There must be a written maintenace and renewal programme that details all the proposed, and on-going environmental improvements with timescales. There must be a staff training and development plan for the whole staff team (when complete a copy should be sent to the Commission in this instance), and staff must have all the mandatory health and safety training. Eldra Court must have a quality assurance system. Timescale for action 10/07/06 10/03/06 10/03/06 10/04/06 5 YA35 18(c) 10/05/06 6 YA39 24 10/06/06 Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Good Practice Recommendations Standard YA4 Eldra Court should have an admissions procedure. YA5 Each resident should have a contract. YA23YA12YA7 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. YA20 Medication not typed on medication records should be checked and signed by two staff. YA22 Eldra Court’s complaints procedure should be understood by residents. YA30 There should be a written kitchen-cleaning programme, and a food probe should be used to test the temperature of cooked meat. YA32 At least 50 of care staff should have NVQ 2. YA33 Staff meetings should be recorded. YA34 There should be an interview format for recording decision-making about employment. YA35 Staff training records, including copies of certificates, should be kept in the Home. YA36 Regular staff supervision should take place. YA40 All the required policies and procedures should be in place. YA42 A file should be kept in the home of all the health and safety checks that take place regularly. The registered manager should inform the Commission of incidents, which have a detrimental effect on residents. 4 4 5 6 7 8 9 10 11 12 Eldra Court DS0000064403.V270451.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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