Inspection on 05/06/07 for Eleni House

This inspection was carried out on 5th June 2007.

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

Eleni House 15/05/08

Eleni House 04/12/06

Eleni House 08/12/05

Eleni House 30/11/04

Eleni House 13/05/04

Eleni House 13/05/04

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 Eleni House Boxted Road Colchester Essex CO4 5HF Lead Inspector Jane Greaves Unannounced Inspection 5th June 2007 09:30 Eleni House DS0000017810.V342526.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 Eleni House DS0000017810.V342526.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. Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eleni House Address Boxted Road Colchester Essex CO4 5HF 01206 842457 01206 842457 manager_eleni@careaspirations.com 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) Care Aspirations Limited Mr Joseph Francis Walker Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 8 people under the age of 65 years with a learning disability who may also have a physical disability 4th December 2006 Date of last inspection Brief Description of the Service: Eleni House provides care for eight adults with a learning disability. Service users have a range of complex needs, such as epilepsy and self-injurious behaviour. Eleni House is a purpose-built bungalow, built in 1997. It is one of several units grouped together on the outskirts of Colchester. It has eight single bedrooms, four of which provide en-suite facilities. The accommodation is spacious, with good access for wheelchair users and includes a lounge, separate dining room, sensory room and recently added spa pool. Attached to the unit is a sensory garden. The home has a mini bus and a pool car for service users. The weekly charge for a room at Eleni House is between £879.81 and £1435.32. An extra charge is made for hairdressing, toiletries and chiropody. Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector went to the home without telling anyone she was going to visit on Tuesday 5th June 2007. During this visit the inspector • • • • Talked with the manager, one person living at the home and some staff members. Looked around some of the home Looked at records Watched how the people living at the home and the staff got along together. In writing this report the inspector used information gathered prior to and during this visit. Some family members were spoken with as part of this inspection, all comments received were very positive about the care their relatives received at Eleni House. 22 of the 43 National Minimum Standards and the intended outcomes of these were assessed at this visit: There was 1 requirement resulting from this inspection, and some good practice recommendations have also been made. What the service does well: • • • • • Eleni House is a small, clean and comfortable place, with a stable, family atmosphere. Staff supported the people living at the home to be as safe as possible. Staff did the right things to keep people healthy and supported them well when they became ill. There are enough staff on duty to keep people safe. Family members reported: “My relative is very happy at the home, everyone is very kind” “They are truly wonderful” “They have done everything possible to make my relative happy and comfortable” “They do their very best to give my relative a quality of life that is very supportive” “I feel Eleni House could not be bettered in the care and support of my relative” Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? • The staff rota had been developed to accurately reflect where staff were supporting the people living at Eleni House or working housekeeping shifts. Staff notice boards had been removed from the communal areas to make the environment more homely in appearance. • What they could do better: • The law says that staff records (needed to make sure that people living at the home are in safe hands) must be kept at Eleni House. Some of their records were still held at Care Aspirations main office. The people in charge must see that staff have all the training they need to keep everyone living at the home as safe as possible. The person in charge must make sure that the dignity of the people living at the home is promoted by making sure that signs relating to their personal care needs are not placed on the walls in full view. The person in charge should make sure that repairs are made to bedroom doors to promote the dignity and privacy of the people living at the home. The person in charge must make sure that all areas of the home are kept clean and fresh including the kitchen and individual bathrooms. • • • • 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. Eleni House DS0000017810.V342526.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 Eleni House DS0000017810.V342526.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were not admitted to the home without having a full assessment of their needs and wishes undertaken by a person trained to do so. EVIDENCE: There had not been any new admissions to this home since the previous inspection site visit. The policies and procedures for admitting new residents to the home were in place and remained subject to regular review. Eleni House DS0000017810.V342526.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person living at the home had an individualised plan of care ensuring support is tailored to their specific needs and wants. EVIDENCE: Support plans for two people who live at the home were sampled as part of the inspection process. These contained clear detail of the actions staff needed to take to support individuals to live an independent lifestyle to the maximum of their capabilities. The files contained a detailed personal profile and support plans for all areas of daily life, all relevant to the individuals’ specific needs and lifestyle. The people living at Eleni House had such complex needs that the process of offering choices involved trial and error. This was reliant on the support staff knowing individuals’ reactions well and being able to gauge individuals’ likes and dislikes. Care plans contained good information about peoples’ likes, dislikes, needs and wants. Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 10 Risk assessments were present for incidence of physical and verbal aggression, wheelchair use, trampolining, swimming and medication amongst others. Once a risk had been identified a corresponding care plan was developed and goals and strategies were introduced to reduce or remove the risk. There was no system of cross-referencing in place to link the risk assessment and care plan. The support plans and risk assessments included evidence to confirm reviews took place; the interval between reviews was dependent on the individual needs and circumstances at the time and varied from a few days to a year for examples seen. The home’s arrangements for supporting individuals with their personal monies were assessed at this visit. It was reported that some people had building society accounts where savings where transferred. The registered manager reported difficulty in arranging bank accounts for individuals with such complex needs. There was a clear audit trail of all financial transactions on behalf of the people living at Eleni House, on the two random balances sampled receipts were cross references with records and the cash held was counted and found to be accurate. Eleni House DS0000017810.V342526.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. 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service were supported to make choices about their lifestyle. EVIDENCE: Each person living at the home had a weekly programme of activities within their care plan. The home had a ‘directory’ of ideas for activities and outings that individuals living at the home enjoy. These varied from a jaunt to the local pub or a trip to the theatre to weekend events in the summer such as air displays etc. Activities such as trampolining, cookery, hobby craft, family visits and hydrotherapy sessions take place routinely. Annual holidays had been organised for the people living at the home. Some were going on a caravan holiday and others were going to Centre Parks. Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 12 Observation on the day showed that the household routines were dictated by the needs of the people living at the home. Mealtimes were planned around activities undertaken. Menus spanning four weeks were displayed on the wall in the kitchen. Support staff on duty undertook shopping and meal preparation. The kitchen was of a good size but was starting to show signs of wear and tear. Some cupboard fronts were damaged and wipe clean surfaces were compromised. Discussions were held with the registered manager about the potential refurbishment of this area. Eleni House DS0000017810.V342526.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that the people living at Eleni House received was based upon their individual assessed needs. EVIDENCE: Files relating to the healthcare needs of the people living at Eleni House contained clear information of individuals’ health needs and how these were to be met. The delivery of personal care was individual and flexible according to changing needs and preferences. Arrangements for supporting people to remain healthy had not altered since the last inspection. It was evident from discussion and records that the home was proactive in obtaining the appropriate medical attention for individuals and access to NHS facilities. Arrangements for the administration of medicines maintained in the home had not altered since the previous visit where this standard was assessed and the home’s procedures were judged to be appropriate to protect the health, safety Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 14 and well being of the people living at the home. Staff responsible for the administration of medicines had received training relating to the Monitored Dosage system operated at the home. There had not been any refresher training provided for the staff team and the registered manager reported the lack of awareness of the need for refresher training. The home does not have a system to assess the competency of support staff when administering medications. A Pharmacy audit was scheduled to take place at the home, the manager reported the intention to arrange refresher training for the staff responsible for the safer administration of medicines within the service. Eleni House DS0000017810.V342526.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Eleni house and their relatives/representatives were confident their views were taken into account and acted upon EVIDENCE: Eleni House had a comprehensive complaints policy and procedure in place to ensure that the people living there and their families and representatives were able to voice any concerns they may have and be confident that they would be listened to and taken seriously. The home had no recorded complaints since the previous visit. Discussions took place with the registered manager and the Human Resources department of Care Aspirations limited around ensuring the appropriate documentation is available to confirm that all the necessary checks to ensure the health, safety and welfare of people living at the home are made before new staff start to work there. Two staff files for persons recruited since the previous visit were examined. The address portion at the top of the Criminal Record Bureau Disclosure (CRB) was retained on the staff file at the home; the remainder was reported to be stored centrally at Care Aspirations. Where a member of staff had started to work before the full CRB was returned there was evidence that checks had been made against the Protection of Vulnerable Adults list. The registered manager was not able to confirm if the organisation had a policy to renew CRB checks after a prescribed period of time. Information gathered from Human resources confirmed that there was no hard Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 16 and fast policy however staff terms and conditions of employment stated that any behaviour resulting in legal action must be notified to management. Eleni House DS0000017810.V342526.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home provides the people who live there with a safe, well-maintained and comfortable environment. EVIDENCE: The physical environment of the home was appropriate for the needs and requirements of the people living there and was homely, clean, safe and comfortable. Visitors were able to meet with residents in the communal areas of the home or in their private rooms. Bathrooms and toilets contained the appropriate adaptations required by to promote their safety of the people who live there. One en-suite bathroom smelt musty and damp. This was discussed with the registered manager. The previous inspection identified that the use of ‘signage’ around the home was excessive and detracted from the homeliness of the environment. Two Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 18 notice boards had been removed subsequent to the previous visit but many signs were still in evidence. Staff and management agreed that the effectiveness of signs diminishes with time and most are not even noticed by the people they are intended for. One sign on the dining room wall gave specific detail of strategies for one individual who lives at the home. This did not serve to protect or promote this individual’s dignity. In individual bedrooms there were signs relating to personal care tasks, discussion was held with the registered manager around finding alternative ways to provide the support staff with the information needed whilst protecting individuals’ dignity. Two individuals’ private bedroom had small round holes, it was reported that this was where locks had been incorrectly fitted and that this was waiting to be repaired. One bedroom door had a broken lock and catch, this had been reported. Some of the bedrooms opened out onto a patio area, all the planting was edible to ensure the safety of people living there. Care Aspirations had appointed a Health and Safety officer. This role included visiting the home three monthly to undertake Health and Safety Audits and the remit will include delivering Infection Control Training to the staff team. The kitchen units were ‘tired’ with damage to ‘wipe clean’ surfaces. Eleni House DS0000017810.V342526.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, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in appropriate numbers to meet support the people who live there. EVIDENCE: The staff rota provided evidence to show that daytime staffing numbers vary between 7 – 9 support staff depending on the needs of the people living at the home. This reduces to 5 staff after 5 pm and 3 staff on night shift. One member of staff works housekeeping shifts as well as care shifts, discussion was held with the registered manager around documenting these shifts appropriately. Staff recruitment records were examined for two recent employees, insufficient information was available at the premises relating to the pre-employment checks made necessary to promote and protect the safety of people living at the home. Human resources department were able to confirm subsequent to this visit that all necessary checks had been made. Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 20 Evidence was available to show where staff members were booked to attend training courses for the Protection of Vulnerable Adults from abuse. Other gaps were identified in the training schedule however the registered manager was able to demonstrate where refresher course had been booked. Discussion was held with the registered manager around ensuring that accurate staff training records are maintained. Eleni House DS0000017810.V342526.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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. EVIDENCE: The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. The registered manager was not always enabled to fulfil his responsibilities under regulation due to Care Aspiration’s policies and procedures. One example was that the registered manager did not always have the responsibility of recruiting staff members for his own team. Subsequent to this visit the registered manager reported that this situation had changed and he was now able to select staff appropriate for Eleni House and the people that live there. Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 22 The registered manager does not have access to the Criminal record Bureau checks made as part of the recruitment procedures and these are not maintained at the care home. The service operates an external quality assurance system ‘BenchmarQ’, this system incorporates surveys from family members and other representatives of the people that live at Eleni House. A report is written from the results of the surveys. The people who use this service are clearly identified throughout the report. In the main, arrangements for promoting and protecting the health and safety of residents and staff had not changed since the previous visit and remained satisfactory. Eleni House DS0000017810.V342526.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 X 5 X 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 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Eleni House DS0000017810.V342526.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 YA23 YA34 Regulation 17 Shed4 19 Shed 2 Requirement For the protection of the people living at Eleni House, evidence must be made available to show that checks are carried out on all new staff before they start work at the home to be sure they are safe to work with vulnerable people. This is a repeat requirement that did not agreed previous agreed timescale of 31/01/07 Timescale for action 30/09/07 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 YA9 Good Practice Recommendations It is recommended that a system to cross reference the risk assessments for the people living at Eleni House with the relevant section of the care plan to provide an audit trail for support staff to follow. It is recommended that the kitchen facilities are updated DS0000017810.V342526.R01.S.doc Version 5.2 Page 25 2 YA17 Eleni House ensuring that all surfaces are ‘wipe clean’. Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. Extracts may not be used or reproduced without the express permission of CSCI Eleni House DS0000017810.V342526.R01.S.doc Version 5.2 Page 27 - 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!