Inspection on 22/11/05 for Ellens Court

This inspection was carried out on 22nd November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ellens Court 16/12/08

Ellens Court 11/03/08

Ellens Court 17/09/07

Ellens Court 06/10/06

Ellens Court 07/06/05

Ellens Court 15/03/05

Ellens Court 09/02/05

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

CARE HOME ADULTS 18-65 Ellens Court Lady Margaret Manor Doddington Sittingbourne Kent ME9 0NT Lead Inspector Brenda Pears Announced Inspection 22nd November 2005 09:30 Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ellens Court Address Lady Margaret Manor Doddington Sittingbourne Kent ME9 0NT 01795 886220 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) Mrs Lynn Brooks Mrs Lynn Brooks Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Ellens Court is a 9 bedded home providing 24 hour care to adults who have a learning disability. The business is privately owned by the registered manager. The home is located in a rural setting approximately one and a half miles outside the village of Doddington. The property is detached and the accommodation is located on 2 floors. The upper floor consists of 5 single bedrooms and a W.C. The ground floor has four single bedrooms, a large comfortable lounge, a separate smaller lounge, a shower room, a bathroom, further W.Cs, a kitchen, laundry and a dining room. There are several outbuildings including a games room, a workshop, and a kitchenette that is used to promote independent living skills for the service users. The property has extensive grounds that are attractively laid out and well maintained. The care staff work to a flexible shift pattern and there is one member of staff on waking duty at night. In addition to care staff the home also employs domestic catering staff and an administrator. The owner undertakes day-to-day management and also provides care and out of hours support when needed. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the inspection consisted of speaking with the manager, staff and service users. The methods of inspecting the home included checking records, tracking service user care plans, observations and a tour of the building. The focus of this inspection was on monitoring the requirements and recommendations from the last inspection, the core standards and the quality of life for service users in the home. As part of the pre-inspection process, residents and relatives were consulted for their views of the home. The service users and families returned their comment cards, providing valuable feedback about the home, which helped in the planning of this inspection. Some comments received on questionnaires includes ‘Excellent staff in excellent surroundings’ and ‘The only home to make a difference to a person’s way of life’. The home was found to be clean, odour free, comfortable and welcoming with a relaxed atmosphere. The main building was warm and service users appeared comfortable and stated they are well cared for and happy and staff were seen to be undertaking their duties with due consideration for independence and choice. All service users were aware of the announced inspection and were happy to allow access into their rooms and sit and discuss their day with the inspector, providing valuable information to support the outcomes of this report. What the service does well: What has improved since the last inspection? The out building in the grounds that is at risk of collapse has now been fully cordoned off, risk assessments are in place and this structure is also due to be demolished. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 6 Supervisions are currently being recorded and these meetings are also to become more formally carried out when a mutual format has been agreed between the staff team. The external grounds have been cleared, the grass has been cut and all areas appeared well maintained. Clinical waste is now being collected by the local council on a regular basis. 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. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Files contain full and thorough information regarding service user needs and daily records contained appropriate information and observations that ensures full needs are met. EVIDENCE: Discussions with service users and a sampling of files confirm that service user aspirations and needs are very much part of daily routines. The questionnaires received prior to this inspection also state that staff support and provide care that is appropriate to service user needs. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 All activities are undertaken following discussions with each service user, supporting choice and autonomy. Service users were at the centre of all activities at this time and were fully included in the inspection process, supporting autonomy and independence. EVIDENCE: Staff members ensure the wishes of service users are sought and that inclusion is undertaken at all times. This was evidenced at this time by staff constantly asking the preference of the service users present and full inclusion was observed during this inspection. Choices are offered at all times with each day being spent as the individual wishes. Planned outings/activities are only undertaken if the service user wishes, if refused, alternatives are offered until a suitable activity is decided upon. Service users stated they only take part when they choose to do so and some people had been out to the shops during the morning but others had chosen to remain in the home. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 16 Service users enjoy their chosen activities and staff showed due consideration for choice and supported each person to undertake full responsibility for their activities at this time. EVIDENCE: Some activities enjoyed by service users at this time include one person at day centre, four people went by car to the shops and others enjoyed reading newspapers and watching television in the home. Those people who did not go to the shops during the morning will later have an opportunity to travel to collect the service user from the day centre and also have a drink or snack out if people choose to do so. There is also a games room available with a snooker table and arts and crafts and sensory activities are also undertaken regularly. Staff stated they deal in a positive manner by offering a choice of activities and waiting for service users to decide, staff do not just ask if anyone wants to do something as this can often encourage a negative response. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20 Staff expressed a good knowledge of service user needs and were seen to be supporting service users in an appropriate manner. Medication was carefully administered, was not rushed and service users are aware of the importance of paying full attention during this procedure. EVIDENCE: Service users confirmed they are supported by staff and are happy with the way help is given. Staff were observed to be giving due consideration for autonomy and privacy at all time. Medication is appropriately stored and service users are aware of the importance of the routines being undertaken at this time. Staff gently reminded one service user that medication was important and discussions would take place when all medication had been administered. The incident records evidenced clear and full details of any areas of concern and what action is to be taken. The daily moods of service users and how the day has been spent are clearly recorded to ensure appropriate support is given at all times. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users feel their views are listened to and acted on. EVIDENCE: Discussions undertaken with service users, observations and questionnaires received prior to this inspection all confirm that staff listen to the views of service users and support them at all times. Locked facilities are available for service users in their room to retain any valuables and no member of staff is appointee for any service users in the home. All purses and wallets are locked safely until these are needed and when taken out, balances are checked and signed by 2 staff with all spending being supported by receipts that are kept on file. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 & 30 The home was found to be clean, comfortable and welcoming with a relaxed atmosphere. The main building was warm and service users appeared comfortable and stated they are well cared for and happy. EVIDENCE: The outer buildings and the external corridor are in need of upgrading, particularly the laundry area as this is currently quite small for the work that needs to be undertaken in this area. However, the manager is fully aware of this and has plans for upgrading some of the external areas. These areas were found to be clean and supported the needs of service users. Numbers of staff and service users are checked when meals are taken in the dining room to ensure complete safety at all times and buildings are locked when not in use. Individual rooms were seen to be personalised, comfortable and with some rooms having shelves as dividers that provide additional private areas. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 14 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): 35 There is a training matrix in place and staff have undertaken refresher courses as required. EVIDENCE: A training matrix is in place to support the ongoing training programme in the home. Some training undertaken recently includes awareness of autism, severe challenging behaviour, knowledge of brain damage plus physical and psychological challenges. Staff are also on NVQ level 2 trainings and one member of staff has attained NVQ level 4. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 15 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): 39 & 42 Service user views are obtained regarding developments and routines in the home. The home protects and promotes the safety and well being of service users. EVIDENCE: Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 16 The safety, health and well being of service users is considered at all times and the home was found to be clean and fresh in all areas, both internally and externally. All staff are trained in the safe handling of medication and clinical waste is to be collected regularly by the local council. Service users are kept safe at all times through regular checks on their whereabouts at times when activities or routines mean some people have to leave the main building. All areas are locked when not in use and doors are alarmed at night. Service user opinions and wishes are considered in all future developments and plans for the home. Questionnaires have been sent out to the next of kin and service users also completed questionnaires for this inspeciton. The manager stated that families keep in close contact with the home and service users also discussed forthcoming visits with excitement. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ellens Court Score 3 X 3 x Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 x DS0000023931.V253498.R01.S.doc Version 5.0 Page 18 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard 42 36 Good Practice Recommendations Staff must ensure all food and fridge temperatures are taken and recorded in the absence of the cook. That staff supervision continues to be developed to ensure staff and service users are supported appropriately. Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ellens Court DS0000023931.V253498.R01.S.doc Version 5.0 Page 20 - 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. 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