Inspection on 03/05/07 for Essex Care Consortium Marks Tey

This inspection was carried out on 3rd May 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Essex Care Consortium Marks Tey 01/12/05

Essex Care Consortium Marks Tey 12/07/05

Essex Care Consortium Marks Tey 25/01/05

Essex Care Consortium Marks Tey 17/08/04

Essex Care Consortium Marks Tey 15/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Essex Care Consortium: Marks Tey Station Road Marks Tey Colchester Essex CO6 1EE Lead Inspector Tim Thornton-Jones Key Unannounced Inspection 3rd May 2007 09.15 Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.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: Marks Tey DS0000017967.V339285.R02.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: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Essex Care Consortium: Marks Tey Address Station Road Marks Tey Colchester Essex CO6 1EE 01206 211825 01206 211825 ecareinfo@btconnect.com www.e-care-c.co.uk Ms Bethan Jess Oliver Ms Gillian Oliver Patricia Owen Care Home 13 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 (13) registration, with number of places Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 13 persons) 1st December 2005 Date of last inspection Brief Description of the Service: The service is comprised of three dwellings occupying the same site. The largest dwelling provides for eight younger adults, who have a learning disability. The bungalow accommodation enables each person to have their own bedroom and to share other communal spaces. The second dwelling is a smaller bungalow accommodating four adults with similar disabilities, although persons within this bungalow have more complex needs. This dwelling is selfcontained and provides each person with separate facilities. The remaining dwelling consists of a self-contained studio flat on the ground floor, which provides for one person. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken on one day. The manager was in attendance for the most part and assisted the inspection in addition to other staff in a helpful and co-operative way. Overall the service has a good and positive outcome and whilst no service users were available to discuss the service with, questionnaires completed prior to the inspection by service users and other stakeholders were available. The weekly fees were advised as being £688.04 to £1942.65. What the service does well: What has improved since the last inspection? What they could do better: • The quality assurance system is being adjusted to ensure that the approach engages fully with service users and their representatives and this was not yet fully operational at the time of this inspection. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 6 • Care workers who undertake the administration of prescribed medicines had not followed the internal organisational policy and practice procedure and this will need to be improved. Staff who deliver care to service users require regular formal supervision. The organisational policy and practice procedure meets with the same outcome as National Minimum Standards in terms of frequency of supervisory sessions, which had not been fully maintained and therefore a review of practice is required. • 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: Marks Tey DS0000017967.V339285.R02.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: Marks Tey DS0000017967.V339285.R02.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): Standard 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • • Service users have all the information they require to make choices about the service. The policy and procedure regarding admissions to the service reflect good practice and ensure appropriate transition into the service. EVIDENCE: The manager of the service confirmed that no new service users have come to live at the service during the period since the previous inspection. The Statement of Purpose and Service Users Guide and other service user information was available but not inspected. At the time of the fieldwork visit the inspector was of the view that the documents were unchanged since the previous inspection. Subsequent to the visit the registered person advised that the documents had, in fact, been amended and that at the time of the visit the revised documents were being reprinted. These documents will be fully reviewed at the next inspection of the service. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 9 The documents are produced in easy read and symbol format for ease of use by service users. At the previous inspection the policy and practice procedures regarding admissions into the service were found to meet with National Minimum Standards and in the absence of a current opportunity to assess the practice, the National Minimum Standard was considered to remain as met. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.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): Standards 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. • Service users benefit from the care planning approach to enable choices and decisions about their lives including taking responsible risks. EVIDENCE: Care planning arrangements were sampled using two service users files as a case tracking exercise. On this occasion it was not possible to speak with the service users directly as they were not at home throughout the duration of the inspection. The care planning structure is well planned and contains data relating to risk assessment from which care decisions are made. The plans viewed indicated that the approach was with the consent and co-operation of the service user. The plans were produced in easy read and symbol format (Widget) and most care plans in use are produced in this style. The organisation has developed Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 11 an environment of ‘inclusive communication’ and this continuity of approach is underpinned with actions throughout the organisation as far as practicable. Whilst each care plan addresses individual needs and preferences the structure and format of the care plan document was understood at the time of the visit to be similar for all service users and in view of the wide variety of communication and level of understanding among service users, the organisation was advised to take care to avoid a ‘one size fits all’ approach. Subsequent to the fieldwork visit the registered person advised that some care plans are not produced in symbol format on the basis that some service users are able to understand easy read formats. This is acknowledged although care plans in this alternative format did not form part of the sample during the fieldwork visit. An alternative sample will be taken at the time of the next visit. Overall, the practice that underpins care planning is ‘person centred’ and individual, acknowledging that different people require different types of planning approaches. The service has a suitable risk framework and the tools used are appropriate to safeguard service users whilst encouraging maximum independence. The file management was observed to meet the requirements of confidentiality and security. Service users finances are held in safe custody by the service. Service users have individual bank accounts although the records of these were not viewed on this occasion. Service users who require larger amounts of their money complete a request form, which is sent to the service sister site in Birch, where the cash is obtained and returned with the request form to the home. The overall practice arrangements were reviewed and sample cash balance checked. The arrangements viewed were accurate and secure. It was noted that the security and recording/checking arrangements have been revised and improved. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 12 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): Standards 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. • • • • Service users benefit from the various choices made available that develop and influence their individual lifestyle. The arrangements for links with families and friends are positive and form an integral part of the service culture. Service users do benefit from the encouragement they receive to achieve balance between their rights and the responsibilities they have in living as part of a small community. The catering arrangements are overall satisfactory and it is important that the organisation continue to review ways in which this could be developed. EVIDENCE: Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 13 Throughout this inspection, as previously stated, no service users were available to speak with, although a number of service user surveys sent to the service by CSCI had been returned. These confirmed the documents being maintained that all service users attend various day centres, some provided by Essex Care Consortium others provided by the local authority. Some service users also attend Further Education courses. Courses are accessed via the organisation day services centre based at the Essex Care Consortium site at Birch, Colchester. The surveys indicate that service users have a range of choices and responsibilities that shape their lifestyle, from access to social and leisure opportunities to life skills responsibilities such as clothes washing and keeping their rooms clean etc. One person stated on their survey that they assisted with washing up occasionally. The majority of surveys from both service users and relatives commented that the care workers were supportive and friendly and that the organisation was well managed and responsive to all stakeholders. Care plans sampled indicated that positive links are established and good communication exists between the service, service user and relatives. The overwhelming viewpoint from relatives was one of the service being responsive, caring and well organised. The catering arrangements were satisfactory although one relative commented within the survey that the food menu could be improved with more healthy eating options. In discussion with the Manager, service users preferences are taken into consideration when compiling the menu, although service users do not always appear to be involved in the shopping for goods at the supermarket and for household goods, which may be a lost opportunity for those service users who are following ‘ordinary life’ goal outcomes. Subsequent to the fieldwork visit the Registered Manager confirmed that most of the shopping, particularly for food, is done by staff and service users together. It is acknowledged that at the time of the fieldwork visit the Registered Manager was out at the shops shopping for towels, sheets and other household items for the home, although it is understood that no service users were involved in this activity, albeit that service users may well have been consulted regarding the type and colour, for example, of such items. None of the surveys completed by service users commented upon the food provision. Care Workers undertake the task of providing the catering service and the inspection highlighted that not all staff undertaking this task have undergone competence based training relating to food hygiene or basic catering skills, although ‘attendance based’ training has been provided for food hygiene. It is noted however that the recently recruited Deputy Manager is a trained and Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 14 qualified caterer and therefore there may be some potential for developing this aspect of the service further. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.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): Standards 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. • Service users mainly benefit from the arrangements made to support service users with healthcare matters although some development in the supervision and training of carers who administer prescribed medicines is required. The outcome of this group of standards has been judged as good rather than adequate as, overall, there are greater positive aspects to care outcomes. EVIDENCE: Based upon the sample of care plans all service users are registered with the local GP practice and healthcare matters, including optician and dentist are planned in advance for each person. Appointments are taken within the community in keeping with the ethos of the service unless it is necessary for a home visit in the same manner as anyone living within the community. Based upon the sample care files it was noted that the healthcare part of the plan was well designed and enables easy tracking of healthcare appointments Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 16 and follow up actions where necessary. Onward healthcare checks and appointments were in the process of being updated by keyworkers as some plans indicated these had been planned whilst one sample did not. Healthcare professionals were sent surveys and the GP surgery responded but only partially completed the survey. Those parts that were completed were positive. Questionnaires returned from relatives provided a positive overview that the service was good at keeping relatives informed of healthcare matters. It was not possible to discuss the delivery of care with service users at the time of the site visit, although the service user surveys and relative surveys provide some very positive comments about the support and manner in which the care is delivered by care workers. The arrangements for service users prescribed medicine were reviewed. Most service users have their prescribed medicines held in safe custody by the service and are assisted by care workers. The service operates a monitored dosage system supplied by a well known local pharmacy. The medicines are securely held when not in use within a steel lockable cabinet. A sample check was made of the administration system and it was noted that on at least five occasions on different days and at various periods of the day the record showed a blank space where a carers initials or a system code should have been written. This matter was referred to the Manager who confirmed that the person in charge of the medicines on the specific days in question had not completed the record properly. It was not possible to audit the medicines for these occasions since no indication was given whether the medicines had been given, refused, destroyed etc. The remainder of the administration was satisfactory. It will be necessary for staff training needs to be identified and improved where necessary to ensure that carers are able to competently complete the administration record. There are some people living within the service that have a range of competencies that may support a more regular review of assessment regarding the extent to which medicines can be held in safe custody. It is noted that some service users do contribute to the administration of their own medicines and this may benefit a higher proportion of service users with a regular reassessment of risk, rights and responsibilities. It is important to express that medicines held in safe custody on behalf of service users should be undertaken only where risk assessment indicates that the service user is unable to take part in the process at any level and to do so would be unsafe. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.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): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. • Service users are informed and protected by the service arrangements relating to the investigation of complaints and safeguarding adults through the policies, procedures and employee training, although this one incident highlighted that security arrangements were unable to prevent a theft. The judgement for this group of standards is good based upon the manner in which the matter was managed. EVIDENCE: The service maintains a complaint procedure and this is available in easy read and symbol format for those who would find it easier to access and understand. The Manager advised that no complaints have been investigated during the period since the previous inspection although written compliments received by the service had been received. The format of the complaint procedure and its use remains the same as at the previous inspection and therefore continues to comply with National Minimum Standards. The service follows a safeguarding adults policies and procedures and in a similar way to complaints, the format is made easier for people by easy read and symbol formats. The service undertook an internal investigation under the policy relating to one financial matter, the outcome of which was inconclusive in that although the matter was being considered as a theft, the perpetrator was not identified. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 18 The Registered Person replaced the missing finances at their discretion, which was a positive outcome for the service user. All relevant external agencies were appropriately involved and the matter was managed well. The Manager has since increased the security and audit tracking procedures for cash held in safe custody on behalf of service users. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 19 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 excellent. This judgement has been made using available evidence including a visit to this service. Standards 24 and 30. Service users benefit from a safe, homely, comfortable, clean and welcoming environment. The outcome is judged to remain as excellent although the environment will need to receive regular and frequent attention to detail. EVIDENCE: The bungalow environment remains well maintained, clean, well furnished and decorated. One hallway carpet has been removed in favour of wood style laminate flooring, which the manager advised that service users had been consulted about the choice and style. Similar floor covering, although a different design, had replaced the carpet within the dining area due to the risk of staining. In one lounge area, the tops of wall mounted heating radiators had been removed following damage caused by a service user and had been replaced, Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 20 on a temporary basis, with a piece of wood. This has remained in situ since the previous inspection. Whilst functional in preventing exposure from sharp and potentially unsafe edges, the wood did appear to detract a little from the otherwise very well finished and aesthetically pleasing room. See recommendations. The environment, overall, is domestic in appearance and comfortable. The dwelling was clean and there were no unpleasant odours. Overall the standard of accommodation is very good. Externally the premises remain well maintained although one area of boarding along the roof line appears to require some attention. The manager stated this had been noticed and would be receiving attention. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Standards 32, 33, 34, 35 and 36. Service users benefit from the training provided to care workers although it is recommended that key training be delivered on the basis of assessed competence. There are adequate numbers of staff deployed to meet the needs of service users based upon the assessed ratio of service users to carers. Service users must be safeguarded by the recruitment requirements set out in regulation, not all of which were being undertaken at the time of the inspection. Supervision of carers needs to be maintained on a regular basis because it provides opportunity to ensure that policies and practice procedures are assessed in terms of suitable competence. This, in turn, safeguards service users from any departures from good practice. This group of standards has been judged as adequate overall on the basis that improvements are required or recommended. EVIDENCE: Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 22 Two staff files were sampled as a case tracking exercise to assess the service practice regarding recruitment, induction, supervision and training. The first sample was for a carer who commenced working for the service October 2006, being approximately six months. The second example was a person recruited December 2005, being approximately sixteen months. The recruitment practice was sound for both, with the exception of checking employment history. For the first example the carer had left full time education in 2003 and there was no recorded work history until 2006. No explanation was found within the records as to the information gap. The manager was unable to add further explanation. A similar gap was found in work history regarding the second sample. Both carers had participated within a structured induction system and both were working toward an NVQ qualification in care. When recruiting care workers, unless the Registered Person appoints the applicant, the ‘employer’ (in this instance the home manager) must confirm to the Registered Person, in writing, that all of the checks and information required by Regulation have been obtained (See Regulation 19(2 and 4). Both carers had some evidence of having receiving training although it was noticed that some important operational skills training such as ‘Moving and Handling’ and ‘Food Hygiene’ for example were very short courses and were on an ‘attendance only’ basis rather than a ‘competence assessed’ training as would normally be the case for Food Hygiene for example. Where such training can be externally validated and candidates assessed, this is strongly recommended since the care workers also provide the catering service as part of their duties and as such, service users should expect this service to be delivered by a person assessed as competent to do so. Where carers have previously received externally validated and assessed training, it would be reasonable to provide ‘top-up’ training via short courses on an attendance basis at adequate frequency. Other training included Equal Opportunities and Diversity, which is positive. The medicine administration records were not completed adequately and this was identified with the Manager as a staff competence issue. This indicates a training and supervisory need to improve this standard and to safeguard service users from errors resulting from departures from the service policies and practice procedures. The supervision of care workers in undertaken on a day by day basis and via structured arranged one-to-one time between a care worker and a supervisor. The inspection concluded that a positive and helpful relationship existed between the staff team and all appeared to work within a spirit of good humour and co-operation. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 23 For the care worker who had been in employment 6 months, in addition to their induction, two supervisory sessions had been undertaken. For the other worker, in addition to the induction, four sessions had been undertaken. The frequency suggested by National Minimum Standards to provide adequate support is six sessions in a twelve-month period. For the person employed for sixteen months, the frequency of supervision was inadequate assuming the first twelve weeks of employment was following a period of structured induction. The service assesses the number of care workers and hours required to meet the needs and preferences of people living at the home. The method adopted is one based upon the recommendations of the Department of Health. This assessment ratio indicated that for the two separate dwellings that make up the residential home, a total of 478.79 hours per week. This was compared with the care workers deployment record sampled during a recent week of 564.50. The excess hours were considered adequate to cover the non-care related tasks care workers undertake such as cooking, cleaning and laundry tasks, where service users are not involved as part of their life skills activities. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 24 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): Standards 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. Standards 37, 39 and 42. The home is competently managed and run in the best interests of the people who live there. EVIDENCE: The Manager has been in post for an established period and is both appropriately qualified and experienced. The management style within the service is, overall, well organised and delivered within a relaxed and supportive manner. The ethos appears to be one of encouragement and proactivity. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 25 The organisation has achieved a standardised, externally validated, quality assurance scheme in addition to the Investors In People Award. The quality assurance does not effectively address the qualitative aspect of the service delivery in terms of seeking consumer views, collating the information, identifying challenges to quality outcomes and formulating an action plan that steers specified improvements to the service that assures a satisfactory care outcome for service users. The Registered Person has been considering more appropriate, reliable and realistic methods to engage with service users and other stakeholders. At the time of inspection the quality approach was focussed at service user meetings and although some meetings had been held and various data collected based upon service user views, no analysis had been undertaken in relation to how the perceived quality standards within the service were being met. As a consequence the service had not yet had opportunity to formulate a plan of improvement to the service quality. The service has fire detection systems, fire extinguishers, emergency lighting system, portable appliance checks and care of Substances Hazardous to Health (COSHH) strategy. Where appropriate, these systems are regularly checked by external contractors on a rolling basis. On visiting all of the communal areas of the premises and the outside, no obvious health and safety matters were raised or were noticed. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 26 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 2 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 2 X 3 X 2 X X 3 X Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Timescale for action 13(2) The Registered Person must 30/06/07 ensure that arrangements for the recording and safe administration of prescribed medication are undertaken to safeguard service users from errors arising from departures of the homes policy and practice procedures. 18(1)(a) The Registered Person must 31/07/07 18(1)(c)(i) ensure that carers are 18(2)(a) competent in tasks they are 19(4)(b) expected to do and receive regular supervision. Staff recruitment practices need to be improved to meet regulatory requirements. The area of staff recruitment, supervision and competence is important to ensure that service users are safeguarded and that carers are able to deliver a safe and appropriate service. 24(1) The Registered Person must 31/07/07 ensure that the service has a quality assurance approach that takes the views of service users and their representatives into account in deciding what services to offer them and the DS0000017967.V339285.R02.S.doc Version 5.2 Page 28 Regulation Requirement 2 YA32 YA34 YA36 3 YA39 Essex Care Consortium: Marks Tey manner in which such services are to be provided. This is to ensure that service users shape and have positive influence in the service to improve care outcomes. 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 YA24 YA32 Good Practice Recommendations It is recommended that the temporary wood cover fixed to heating radiators in the lounge area be removed and replaced with a fitted replacement part. It is recommended that care staff who undertake important operational tasks requiring a degree of skill in order to keep service users safe, receive training that is externally validated and competence assessed. Essex Care Consortium: Marks Tey DS0000017967.V339285.R02.S.doc Version 5.2 Page 29 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. 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