Inspection on 26/06/07 for Essex Care Consortium Colchester

This inspection was carried out on 26th 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Essex Care Consortium Colchester 24/06/08

Essex Care Consortium Colchester 26/01/06

Essex Care Consortium Colchester 01/03/05

Essex Care Consortium Colchester 14/09/04

Essex Care Consortium Colchester 15/03/04

Essex Care Consortium Colchester 28/08/03

Essex Care Consortium Colchester 13/08/02

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

CARE HOME ADULTS 18-65 Essex Care Consortium Colchester Maldon Road Birch Colchester Essex CO2 0NU Lead Inspector Tim Thornton-Jones Unannounced Inspection 26th June 2007 10:30 Essex Care Consortium Colchester DS0000017838.V344335.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 Essex Care Consortium Colchester DS0000017838.V344335.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. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Essex Care Consortium Colchester Address Maldon Road Birch Colchester Essex CO2 0NU 01206 330308 01206 331811 ecarecinfo@btconnect.com www.e-care-c.co.uk Ms Gillian Oliver Ms Bethan Oliver Ms Katrina Lingley Care Home 19 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) Category(ies) of Learning disability (19) registration, with number of places Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 19 persons) Children of either sex, aged between 16 and 18 years of age, who require care by reason of a learning disability (not to exceed 18 people) 26th January 2006 Date of last inspection Brief Description of the Service: The service consists of two main dwellings, of bungalow design and a single self-contained first floor studio apartment. Other buildings on site include office accommodation and a day services centre. The site is within a rural location, set in several acres of grounds. The facilities include substantial outdoor activities, including a swimming pool. The service has its own transport via multi purpose vehicles; in view of the location this is an important provision. Public transport, however, does pass the premises and provides access to Colchester town centre to the east and Maldon to the west. The service offers a wide variety of support to adults who have a learning disability. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken in one day. A tour of the premises was undertaken where all communal areas and some bedrooms were viewed. Some of the homes records, policies and practice procedures were viewed, staff were spoken with and managers assisted throughout the inspection. The organisation submitted an Annual Quality Assurance Assessment form, referred to within this report as the ‘AQAA’. Surveys to stakeholders were circulated via the home, and most were returned to inform this report. For this inspection an ‘Expert by Experience’ attended, referred to within this report as ‘EBE’. The person has a learning disability and was supported by an independent person. The main role of the EBE was to meet with people living at the home and to form an independent view about the quality of the service from the perspective, as far as possible, of the people who live at the home. The EBE was in attendance at the home for approximately three hours. The weekly fees were confirmed to be between £590.00 and £2220.00 per week. Fees are set on an individual basis according to assessed need and may include components for use of day services. What the service does well: The service continues to obtain positive feedback from people who use the service and their representatives. The organisation maintains a professional ethos and has continued to maintain externally validated quality status. The carers are helpful and go about their tasks in a friendly and cheerful manner. The policies and procedures of the service are well defined and those specifically for use by service users are well produced and informative. The proportion of carers who have attained a professional qualification remain high. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Essex Care Consortium Colchester DS0000017838.V344335.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 Essex Care Consortium Colchester DS0000017838.V344335.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): Quality in this outcome area is ‘good’ based upon standards 1 and 2. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information and support they need to make an informed choice about where they live. EVIDENCE: The Statement of Purpose and Service User Guide have been recently revised and updated. The documents are comprehensive and well presented. The service also produces addition information about the service. Information is presented in suitable formats. The EBE looked at some information about the home and thought it was clear and easy to understand and stated “there are symbols to help people understand some of the words and there are photos of the home so people can recognise it”. A review of the admission procedure was based upon a case tracking approach. A person was admitted to the service in April 2006, this being the last occasion when admission procedures were used. On this occasion the admission was well planned and co-ordinated between the previous placement of the person and the home with the support of the relevant local authority. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 9 It was noted that the local authority did not provide a suitable assessment to the home prior to admission, as required by regulation, although the home did request one. The home undertook their own assessment and the previous placement compiled a detailed leaving summary. This approach together with a planned admission supported the individual appropriately. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is ‘good’ based upon standards 6, 7 and 9. This judgement has been made using available evidence including a visit to this service. People can be confident that their assessed and changing needs and personal goals are reflected in their individual plan and will be supported to make individual decisions about their lives. EVIDENCE: Care plans were sampled at random and these demonstrated that appropriate decisions were present and ways of working with the person were clear. The decisions were being reviewed appropriately and the review process considers the person and other stakeholders as part of the process. The current plans meet with regulatory requirements. The Manager advised that the care plan format is to be reviewed to ensure the recording tools remain appropriate and as easy to use as possible. The main focus is intended to ensure that the documentation and method meets with the principles of person centred planning. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 11 The service has recently employed a speech and language therapist to develop the current Inclusive Communication Essex (ICE) system developed at the service and care planning will be reviewed in conjunction with this approach to maximise service users involvement in making decisions about their life. Discussion around the style of recording was undertaken to ensure that the method reflect as fully as possible the views of the person within the plan. Some recording had been written by carers in the first part, on behalf of service users, for example, ‘I like to eat sensibly and watch my weight’. Whilst these were not the words specifically of the service user, the style was adopted to encourage carers to think about service users wishes and preferences more readily. Other parts of the plan, such as daily records, are written in a way that carers describe what service users have been involved with such as activities. Whilst the overall plan was good in terms of outcomes, the overall presentation would benefit from review. People have agreed and planned day activities and these vary according to each individual. The service has a day services facility on site called ‘Access’ offering a range of opportunities. This service is separately managed and coordinated from the residential service. Service users also access other services within the community via Frederick House such as further education based in Colchester. Records indicate that people attend swimming and tramp lining for example. The service holds personal monies in safe custody on behalf of people living at the home. The cash and records were sampled at random. All balances seen were accurate and accounted for with the exception of one, which had a small error. The receipt for the transaction and entry did not tally, although the cash balance was correct. A review of the account is required. Each person has an individual bank account. Records for these were not reviewed on this occasion. In discussion with the appropriate manager, the system for financial accounting is to be fully reviewed as part of the quality assurance work the service is undertaking. The current system does present as being complex. The review is intended to create an easier model. Financial records indicate that people enjoy an occasional ‘takeaway’ meal, which fits with ordinary life principles. One entry indicated that carers and service users had jointly purchased a meal for which a receipt had been obtained showing the equal division of payment for each person. The service will need to more readily evidence how people have been reimbursed, where applicable, for the proportion of the meal that would have already been paid for as part of the weekly fees. This has been previously raised and whilst reimbursement arrangements had been confirmed as being in place, there was no evidence available on the day of inspection. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 12 The plan of care is subject to a framework of assessment to ensure that people are empowered to take appropriate risks as part of an individual lifestyle. Assessments sampled were in place to meet a range of circumstances including finance, medicines and other activities where people may be at risk of harm or exploitation. Within some areas of the dwelling doors have entry/exit code keypads. Risk assessments are in place and the infringement aspect of these are included within the sample plans seen. It will be important for the service to review these arrangements against the introduction of the Mental Capacity Act legislation. See recommendation. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is ‘good’ upon standards 12, 13, 15, 16 and 17. This judgement has been made using available evidence including a visit to this service. People can be confident that they are offered a range of planned activities on site and within the community that allow them to participate in social and occupational opportunities. Meals and mealtimes meet with the preferences and lifestyle of people living at the home. People are supported to maintain positive links with friends and loved ones. EVIDENCE: Whilst service users were unavailable to confirm that preferences and activities offered were in accordance with their wishes, records held at the service including care plans demonstrated that activities of a social, recreational and educational nature were being undertaken. These were based both on and off site within the community. The service AQAA states that activities are an area that could be improved and has been relatively limited due to low fee level increases. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 14 Although no relatives were available to speak with at the time of inspection, a number of surveys were returned to CSCI prior to the visit. Without exception all indicated satisfaction with the service and made positive comments about the management and the support received from carers. Annual holidays are arranged resulting from discussions with service users and reflect the preferences of the participating group. Relatives are often included in the arrangements for holidays and this offers the service user an opportunity of relaxing with the family whilst the family feel confident that a carer is available to support the person if needed. Where an individual service user would benefit from a planned activity separately the service is able to facilitate one to one support to enable the activity to proceed. The EBE had opportunity to speak with a number of service users and stated that the home was ”a beautiful place to live, everyone I spoke to liked living there and seemed happy”. The EBE also gained the view from discussion with service users and staff that there were positive lifestyle options such as the home swimming pool and hot tub. Service users also told the EBE that they have choices such as what time people go to bed and the food they eat. The EBE said, “[Service user] said that they were going shopping with there support worker to get food. That’s good as it is more independent”. The house rules within each dwelling are as flexible as possible although some people living at the service do require greater structure and supervision that others due to their disability and consequential behaviour, which is sometimes challenging. Resulting from discussion with staff, observation and the service clear policies and procedures, the daily routine and any required restrictions are commensurate with supporting people to be as independent and empowered as possible. Mealtimes were not observed on this occasion although the planned menus were seen and these demonstrated that a variety of meals were provided. Menus are balanced and reflect variety. Meals are recorded daily. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is ‘adequate’ based upon standards 18, 19 and 20. This judgement has been made using available evidence including a visit to this service. People continue to be supported by the positive ethos of the home and the way in which people are helped to access healthcare professionals. The arrangements for administration of prescribed medicines, however, are not robust enough to protect people living at the home. EVIDENCE: The EBE reported “I saw the carers talk to the service users while I was in the home. They were very nice and service users seemed to like them. When one person was upset some carers tried to make the person feel better” The EBE went on to describe that a number of service users made positive comments about the carers. All service users registered with a local GP and as far as practicable receive healthcare within community settings. The documentation recorded all routine healthcare appointments and carers monitor checks and these as part of their key-working role. From the sample seen the records were up to date and suitably maintained. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 16 All service users have an individual health information file that is portable and can be taken to appointments with them so that both the person and the healthcare professional have current information to hand. The arrangements for prescribed medicines were checked in one dwelling. The administration records were sampled and were completed although for some, the system code was not being consistently used. There were no written notes as to the reason why an ‘x’ was placed on the record since this was not a listed code or a carers initial. One prescribed medicine was found to have run out for approx a week resulting in the person not receiving this medicine for that period. The senior carer was unable to explain why a repeat prescription had not been obtained. The record indicated that the person needed to continue to take the medicine prescribed. The service AQAA states, “Our own policies ensure that two people dispense medication together to minimise the risk of mistakes. All staff are required to undergo training in medication. A weekly check by managers ensures that medication records are up to date”. The quality checking relating to medicine will need to be further revised to ensure a safer outcome. Information regarding the side effects of prescribed medicines being taken by people was located within the care plan. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is ‘good’ based upon standards 22 and 23. This judgement has been made using available evidence including a visit to this service. People are informed and protected by the home’s arrangements for complaints and safeguarding adult’s procedures. EVIDENCE: The manager confirmed that no formal complaints about the service had been investigated during the period since the previous key inspection. The complaint procedure remains the same as that inspected at that time and is produced in easy read format for use by people living in the home. The service had managed one safeguarding adults referral during the period since the previous key inspection. The outcome of this was inconclusive. The process was thorough and well managed. The service is in possession of the current safeguarding adult’s pack and a distance learning pack for carers provided by Essex County Council. The distance learning pack had not yet commenced although based upon sampled staff training; carers were receiving adequate safeguarding adults training. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is ‘adequate’ based upon standards 24 and 30. This judgement has been made using available evidence including a visit to this service. Some aspects of the home décor and fittings prevent a homely and domestic feel whilst other parts meet the needs of people using the service. EVIDENCE: A tour of the buildings were undertaken and all communal areas were visited and some bedrooms. The EBE also viewed the dwellings separately. The EBE stated that the dwellings were homely and that people had nice bedrooms that were comfortable and well equipped. There were a number of photos on the walls and stated “this is really good as it makes it feel like home”. The two dwellings are of domestic proportion, clean and adequately decorated. Some areas are now in need of some routine maintenance and the Manager Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 19 advised that full refurbishment is being planned to resolve these areas and to generally update the environment. In one dwelling a rack containing rubber gloves had been fitted to the dining room wall. The purpose of this was discussed with the senior carer and appeared to be for the quick access for carers. The location of this rack, whilst useful for carers in terms of easy access is not acceptable from an aesthetic standpoint and exudes a rather institutional appearance. Similar racking was fitted in bathrooms and whilst this location is more appropriate it is recommended these be located more discreetly in a cupboard. Since the last inspection there appears to have been signs located in the bathroom to remind staff about bath temperatures. In one bathroom there were two signs of this sort. The bathroom does give an appearance of being quite clinical with white tiles from floor to ceiling and an absence of domestic additions such as pictures for example. The staff signs and the equipment rack located on the wall together with other required equipment and materials do not provide this room with a welcoming atmosphere. The windows within two bathrooms visited had no blinds fitted although did have net curtains. Whilst this would be adequate for dignity and modesty needs during the day, it would be inadequate at night with the room light on. It was noticed that in one bathroom the toilet seat was missing. The senior carer advised that it had broken and was receiving attention Some thought must be given to these aspects of the home and suitable fixtures, cupboards and draws etc be fitted with improved décor suitable to meet the needs of people using the bathrooms and to reflect the homes Statement of Purpose. . See also staff training section. The rooms visited were adequately decorated and clean. unpleasant odours detected. There were no Adjacent to the residential dwellings a new sensory garden was in the process of being constructed for the benefit of service users. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is ‘good’ based upon standards 32, 34, 35 and 36. This judgement has been made using available evidence including a visit to this service. The home carries out robust recruitment practice to safeguard service users. People cannot be fully confident that all the staff caring for them have received regular support and supervision. EVIDENCE: The AQAA submitted by the organisation specified the following; ‘Essex Care Consortium has comprehensive and robust recruitment procedures in place. These are contained in the staff handbooks. No carer starts work until a Criminal Record Bureau (CRB) and POVA first checks are in place along with two references. Applicants are required to complete an application form, attend a preliminary interview and then a further interview with a different manager. On starting work, all support staff are required to complete the Common Induction Standards Induction. All carers have a contract of employment and their own copy of the three staff Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 21 handbooks. (These are regularly updated and a process exists to ensure all carers receive updates for their own handbooks). All carers are subject to bimonthly supervisions with line managers. At these sessions carers will be asked to identify areas of their work where extra training would make them more confident and this will be recorded into their own training profile’. A sample of carer files were examined and the recruitment was found to be robust and in accordance with the service procedures. The frequency of formal supervision did not meet the service own policy and procedures or the frequency requirements out within National Minimum Standards. As previously stated within this report bathrooms did contain staff notices to remind them about taking water temperatures, although this had not been highlighted as a core training need resulting from supervision. Staff training may also be necessary following errors to the finance and prescribed medication system. The files seen indicated that a list of training is scheduled on an ongoing basis, although the training and development approach did not indicate that an assessment of individual training need and impact assessment had been undertaken as set out within National Minimum Standards. Based upon the number of carers employed, more that 50 have attained an NVQ qualification to at least level 2 in care practice. The service has an accredited training forum and has appointed a training manager to lead this initiative. The organisation is aiming to ensure that staff benefit by having access to specific, identified training. Several staff have recently become qualified ‘Personal Intervention’ instructors enabling them to extend this training to more of the staff who work with people whose behaviours present as a challenge. Overall, the organisation has a strong commitment to staff training and development although managers will want to ensure that carers receive instructional training on routine care practices to avoid falling below the practices required within National Minimum Standards. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is ‘adequate’ based upon standards 37, 39 and 42. This judgement has been made using available evidence including a visit to this service. The experience of the manager and the development of well managed systems for health and safety mean that people are safe. Whilst the externally validated quality assurance system has been successful it has yet to adequately assure people living at the home that the service meets with all National Minimum Standards to safeguard their interests and fully meet all their needs. EVIDENCE: The Manager has been employed within the service since 1986 and subsequently developed within the organisation to her present level. The Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 23 Registered Manager has achieved an appropriate care and management related qualification. The organisation is Investors in People employer. The next assessment is scheduled to take place in September 2008. Essex Care Consortium are also registered as an ISO9001: 2000 business with BSi-global. Both these awards recognise specific quality processes for the organisation. The previous assessment reports for each of these awards indicate compliance with the standards required. Internal audits were undertaken. Where problems are identified an action plan is produced and corrective actions are identified along with time scales. The organisation has, however, identified various difficulties in seeking the views of people living at the home, as the quality management scheme mentioned was not initially designed for residential care providers. At present there is no structured method of asking people planned questions and considering the responses within a quality monitoring method that leads to a specific review of the service delivery. A plan has been designed to introduce selected National Minimum Standards based questions into service user meetings. This is intended to engage with service users directly and create some information, which may be used to develop relevant data to assist with producing an annual plan of improvement. This work is yet to be completed. CSCI sent out surveys to stakeholders via the care home and most of these were returned. All were supportive of the management and the staff and expressed satisfaction with the outcomes for the people living at the home. The service operates a range of health and safety systems for fire, emergency lighting, checks for the safety of portable appliances, compliance for prevention of Legionella etc. Records of internal and external contractors were sampled and these indicated that systems were being adequately maintained and were up to date. Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 24 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 3 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 3 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 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 X 3 X 2 X X 3 X Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) 12(1)(a) Timescale for action Service users who have been 31/08/07 assessed as being unable to administer their own medicines must be supported to ensure that prescribed medicines are administered in accordance with their Doctor’s advice. Continuity of medicines must be maintained and the system to monitor this appropriately checked. The home’s premises must be 31/08/07 suitable for it’s stated purpose, safe and well maintained to meet service users individual and collective needs in a comfortable and homely way. This refers to the bathrooms, toilet and dining room. The service must operate an 30/09/07 effective quality assurance and quality monitoring system base upon seeking the views of service users to measure the success in achieving the aims, objectives and Statement of Purpose of the home. Requirement 2. YA24 23(1)(a) 23(2)(c) 12(4)(a) 3. YA39 24(2)(b) Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 26 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 to consider the implications of the Mental Capacity Act in relation to recorded infringements of rights decisions. This refers specifically to the use of coded entry locks to doors. It is recommended that protective equipment located within the bathroom are stored more discreetly. 2. YA24 Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 27 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 Essex Care Consortium Colchester DS0000017838.V344335.R01.S.doc Version 5.2 Page 28 - 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!