Care Home: Eldra Court

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What the care home does well Care is taken to ensure that the printed information given to the residents is presented in a picture format to make it easier for them to understand. Care is taken to make sure that new residents know the home, the staff and the other people living at the home before they move in. Individual care planning is person centred and takes into account the residents social needs and their need to maintain and develop their independent living skills. The people who live at Eldra Court lead active social lives and are actively encouraged to make choices. Careful and detailed care planning enables the staff to provide the right levels of support needed to enable each of the residents to maintain their own personal hygiene. The physical and emotional need of the residents is monitored and where additional help has been needed this has been sought out and provided. Complaints are listened to and taken seriously and policies and procedures are in place to protect the residents from the threat of abuse. Eldra Court provides the residents with a spacious, clean, comfortably furnished and well decorated home. All of the care staff have, or are in the process of completing National Vocational Qualifications in Care. The residents seem to be very happy with the way their home is managed. What has improved since the last inspection? The Statement of Purpose has been revised since the last inspection and now contains all of the required information. The home now has an adult protection policy and a copy of the Alerter`s Guide. All of the care staff have or are in the process of completing National Vocational Qualifications in Care. One to one staff supervision is now being provided at least six times a year for all staff. Regular monthly visits are now being carried out on behalf of the registered service providers. What the care home could do better: The individualised Service User`s Guides have been revised but they still do not contain all of the information that the Care Homes Regulations and National Minimum Standards say that each of the residents need. All records should be signed and dated by the person compiling them and, wherever practical, by the resident that the record is kept for. More care needs to be taken to ensure that the medication administration records are accurate and legible. The registered manager still needs to complete his Registered Managers Award. The registered persons still need to produce an annual development plan for the home, based on a systematic cycle of planning, action and review, reflecting aims and outcomes for the people who use the service. CARE HOME ADULTS 18-65 Eldra Court Eldra Court Third Drive Landscore Road Teignmouth Devon TQ14 9JT Lead Inspector Judy Hill Unannounced Inspection 11 August 2008 10:00 th Eldra Court DS0000064403.V366563.R04.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 Eldra Court DS0000064403.V366563.R04.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. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eldra Court Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Eldra Court Third Drive Landscore Road Teignmouth Devon TQ14 9JT 01626 774834 01626 868127 Education & Care (Devon) Limited Mr Jared John Kenny Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability- (Code LD) - maximum number 7 The maximum number of service users who can be accommodated is 7. Date of last inspection 22nd August 2007 Brief Description of the Service: Eldra Court is registered to provide accommodation and care for a maximum of seven people with learning disabilities. The home is situated in a quiet residential area of Teignmouth and is approximately half a mile from the town centre, beach and train station. Eldra Court provides residential care for former students of Oakwood Court College, which is run by the service provider, Education and Care (Devon) Limited. Information about the service is available from the Home in the Statement of Purpose and a Service Users’ Guide. Copies of CSCI inspection reports will be provided by the home on request or can be obtained from the CSCI website. Weekly fees are assessed on individual needs but from the information available at the time of the inspection range from £726.14 to £1281.62 a week. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use the service experience good quality outcomes. This key inspection included a site visit that was carried out by one inspector on 11th August 2008. The information contained in this report was gained in conversation with the residents and staff who were seen and spoken with at the home during the site visit and the registered manager, Mr Jarad Kenny. Additional information was gained from observing the interaction between the manager, staff and residents. Surveys were completed and returned to the Commission by five of the people who use the service and three members of staff and an Annual Quality Assurance Assessment (AQAA) was completed and returned by the manager. Further information was gained from the homes Statement of Purpose and Service Users Guide, a partial tour of the home and an inspection of records, including individual residents needs assessments, risk assessments and care plans and staff training records. What the service does well: Care is taken to ensure that the printed information given to the residents is presented in a picture format to make it easier for them to understand. Care is taken to make sure that new residents know the home, the staff and the other people living at the home before they move in. Individual care planning is person centred and takes into account the residents social needs and their need to maintain and develop their independent living skills. The people who live at Eldra Court lead active social lives and are actively encouraged to make choices. Careful and detailed care planning enables the staff to provide the right levels of support needed to enable each of the residents to maintain their own personal hygiene. The physical and emotional need of the residents is monitored and where additional help has been needed this has been sought out and provided. Complaints are listened to and taken seriously and policies and procedures are in place to protect the residents from the threat of abuse. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 6 Eldra Court provides the residents with a spacious, clean, comfortably furnished and well decorated home. All of the care staff have, or are in the process of completing National Vocational Qualifications in Care. The residents seem to be very happy with the way their home is managed. What has improved since the last inspection? What they could do better: The individualised Service User’s Guides have been revised but they still do not contain all of the information that the Care Homes Regulations and National Minimum Standards say that each of the residents need. All records should be signed and dated by the person compiling them and, wherever practical, by the resident that the record is kept for. More care needs to be taken to ensure that the medication administration records are accurate and legible. The registered manager still needs to complete his Registered Managers Award. The registered persons still need to produce an annual development plan for the home, based on a systematic cycle of planning, action and review, reflecting aims and outcomes for the people who use the service. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 7 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. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 9 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): 1&2 Quality in this outcome area is good. Time and care is taken to ensure new residents know the home, the staff and the other people living at the home before they move in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Copies of the homes Statement of Purpose and Service Users Guide were provided to the Commission on request. The Statement of Purpose had been updated and revised since the last inspection and was found to contain all of the required information. The Service Users Guide is in large print and individualised versions are provided for the residents in a picture format, which makes the information in them easier to understand. The individual Service Users Guides do however need to be amended, as they do not include the amount and method of payment of fees. A copy of the most recent inspection report is kept at the home and accessible to the residents, their visitors and the staff. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 10 Eldra Court provides a continuing care service for people who have completed courses at Oakwood Court College and have previously lived in the student accommodation. This means that the people who move into Eldra Court have already been receiving a service from Education and Care (Devon) Limited for two or three years. New residents needs assessments are developed from the needs assessments carried out and reviewed when the residents were living in student accommodation. The process of transition from student accommodation to Eldra Court was discussed during the site visit with the most recently admitted resident and the registered manager. The new resident had visited the home five times before moving in and already knew some of the staff and residents from college. Issues of compatibility with the established residents were explored before admission and the new resident was able to make an informed choice about whether or not to move in. The new resident indicated that he had settled in quickly and that he was very happy with his new home. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. Individual care planning is person centred and takes into account the residents social needs and their need to maintain and develop their independent living skills. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for three of the people who use the service were inspected. These records showed evidence of regular reviews, which clearly reflected the changing needs and aspirations of the individual residents. However it was observed that the care planning and review documents are not always signed and dated by the individual residents and the member of staff completing the record to provide evidence of who has been directly involved and when the record was made. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 12 A key worker system is in place and the residents spoken with were able to tell the Commission who their key worker was and how their key worker supported them. The residents rights to make decisions about their day to day lives is respected and this was made evident through their care plans and also by the interaction between the registered manager, staff and services users that was observed during the inspection. Individual risk assessments were seen on the service users files and these included guidance for the staff on how to minimise risks. It was noted that most of the guidance was unobtrusive and, therefore, would not create unnecessary barriers for the residents. Each of the residents has his or her own bank account and withdraws spending money as and when they need it. The home keeps small amounts of money for safekeeping for some of the residents and a record is kept of this. The staff do not use this money to buy things for the residents, who are all capable of doing their own shopping, with staff support if necessary. . Eldra Court DS0000064403.V366563.R04.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): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. The people who live at Eldra Court lead active social lives and are actively encouraged to make choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection five of the residents were seen at the home. The remaining two were staying with their parents for a holiday. The registered manager said that continued family contact is actively encouraged. The Statement of Purpose identifies the primary aim of Eldra Court is to provide continuing care, support and life skills training for people who would be unable to cope in a less supportive environment, such as a supported living scheme, at the time of their admission. The service aims to help the residents to gain their self discipline, confidence, self advocacy, independence and Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 14 confidence and, in some cases, help people to move onto more independent living. The interaction that was observed during the inspection between the manager and staff and the residents provided clear evidence that the manager and staff have a very clear understanding of the aims of the organisation. The residents all lead very active lives and engage in a number of activities of their choosing. The provision of activities is structured and a picture board is used to ensure that everyone knows what they will be doing on any given day. On the morning of the inspection three of the residents went horse riding, one went to town to collect his spending money and do some shopping and one decided that she did not want to go out and so she stayed at home and listened to music. During the afternoon three of the residents went out again and two chose to stayed at home and helped with the inspection. Some of the people who use the service have difficulties with verbal communication, but all five of the people seen were able to express their satisfaction with the service provided and it was a pleasure to spend time with such a happy group of people. The homes Statement of Purpose contains a Resident Charter, which includes the rights and responsibilities of the people living at the home. These include the right to make choices over various aspects of their lives and the residents responsibilities to keep their own rooms clean and hygienic and to attend meetings on time. The residents are encouraged to choose what they would like to eat, although healthy eating is encouraged, and to help to prepare meals. Eldra Court DS0000064403.V366563.R04.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): 18, 19 & 20 Quality in this outcome area is good. The provision of personal and emotional care is very good. The registered manager is aware that he needs to improve medication records. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Careful and detailed care planning enables the staff to provide the right levels of support needed to enable each of the residents to maintain their own personal hygiene. The physical and emotional need of the residents is monitored and where additional help has been needed this has been sought out and provided. The resident’s medication is held and administered by the staff. Although training has been provided, additional training is needed as during an inspection of the records some errors were found. Controlled medication is stored in a suitable storage facility. A controlled record book is kept and this showed that the administration of the medication Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 16 is signed by one member of staff and usually countersigned by the resident. To meet the current guidance controlled drugs should be administered by designated and appropriately trained staff and witnessed by another designated and appropriately trained staff member. Both members of staff should initial the record. There is no reason why the resident should not continue to sign the record as well. Hay fever tablets, which had been prescribed as needing to be taken daily, were being used on a PRN basis. Although it is accepted that the residents may not need to take these tablets daily, this needs to be checked out with the residents GP’s and if it is acceptable for these tablets to be used on a PRN basis, the GP will need to amend the prescription accordingly. Care does need to be taken to ensure that the information that is handwritten on the Medication Administration Record sheets accurately records the information on the container that the medication is dispensed in and that the medication is administered as directed. Eldra Court DS0000064403.V366563.R04.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): 22 & 23 Quality in this outcome area is good. Complaints are listened to and taken seriously and policies and procedures are in place to protect the residents from the threat of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The written complaints procedure has been précised into a pictorial format, which is given to the people who use the service in their Service Users Guides and is kept on display at the home. Information received from surveys completed for the Commission by the people who live at Eldra Court showed that although not all of them understood the complaints procedure, they all knew who to talk to if they wanted to make a complaint. The home has a record book to record complaints but only one had been recorded. This was from a neighbour and had been dealt with and resolved. Written policies and procedures are available to the staff at the home on how to identify and deal appropriately with any suspicions or incidents of abuse and the home has a copy of the ‘Alerters Guide’. The AQAA states that all staff are checked against the Protection of Vulnerable Adults list before they start working at the home and that Criminal Record Bureau checks must be returned before a new member of staff can work alone with the residents. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 18 All staff are required to attend Protection of Vulnerable Adult and NAPPI training in the first six months of their employment. Eldra Court DS0000064403.V366563.R04.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): 24 & 30 Quality in this outcome area is good. Eldra Court provides the residents with a spacious, clean, comfortably furnished and well decorated home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eldra Court is a large detached house, which is set in landscaped gardens is a quiet residential area of Teignmouth. The town centre, beach and railway station are within easy walking distance, although the journey home is a little more strenuous as it is uphill. The home has a large living room and a large kitchen and dining room on the ground floor. Both rooms are very well presented and provide the residents will attractive, comfortable and well equipped communal areas. The laundry room is also well equipped and accessible to all of the people who use the service. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 20 Since the last inspection a number of changes have been carried out to the home. An additional bedroom with en-suite bathroom, which was in the process of being completed during the last site visit has now been completed and a self contained flat has been created to enable one of the residents to have more independence. All of the bed sitting rooms are spacious single rooms and all but one has en-suite bathroom or shower room facilities. The person who uses the bedroom without en-suite facilities has a bathroom, which is exclusively for her use across the landing from her bedroom. All of the bedrooms have been fitted with suitable locks and the residents have keys to their rooms. Two of the people who use the service showed us their private rooms and these very clearly reflected their personalities and individual tastes. There is a communal toilet on the ground floor for staff and visitors to use. The office doubles as a staff sleeping in room. There is a level access to the garden from the front of the house and an access onto a large raised patio area with steps leading down to the main garden from the kitchen. Since the last inspection a member of staff has been working with the residents to create a productive vegetable garden. The home was seen to be very clean and there is a policy in place for preventing and managing infection control. Eldra Court DS0000064403.V366563.R04.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): 32, 34 & 35 Quality in this outcome area is good. The staffing levels were high enough to meet the aims of the service and the needs of the residents at the time of the site visit but need to be kept under review to ensure that this is always the case. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager said that he was very happy with his current staff team and that they all brought different personal skills with them which had helped the home to encourage the residents to try new activities, such as vegetable gardening and horse riding. During the day and evening there are a minimum of two care staff on duty. This is raised to three during busy periods. At the time of the site visit the staffing levels were high enough to meet the needs of the residents, none of whom need constant supervision within their home environment. One care worker provides sleeping in cover at night. The adequacy of this was discussed with the registered manager who said that all of the residents slept well and rarely needed to disturb the member of staff sleeping in. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 22 Feedback from surveys completed by staff indicate that the staffing levels need to be kept under constant review to ensure that they are always maintained at a level that meets the assessed needs of the people who use the service and to ensure that there are enough staff on duty to enable them to meet the aims and objectives of the service, which is to help the residents to do things for themselves rather than have things done for them. Staff recruitment records are not kept at the home but at the Companies office in Dawlish. These were not inspected during the site visit as the Companies current staff recruitment practices had recently been inspected and found to be safe. All of the care staff either have, or are in the process of completing a National Vocational Training qualification in Care at Level 2. One has also completed her NVQ at Levels 3 and 4 and has gained a Registered Managers Award. A list of training courses that the service providers require their staff to undertake is displayed in the office and records are kept of the dates that each member of staff complete the training and the dates when updates will be required. In addition to this additional relevant training is discussed during staff meetings and during one to one supervision. An induction training programme is in place and new staff will be required to complete this within their first six weeks of employment. Records of individual supervision sessions were seen are these are being carried out approximately every six weeks. During the inspection three support workers were seen and one was engaged in conversation in private. She said that she had worked at the home for two years and although the staff were kept busy and she loved her job. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. The residents seem to be very happy with the way their home is managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the registered company, Education and Care (Devon) Ltd, has been sold as a going concern. The new Responsible Individual is Mr Keith Burnley. Jarad Kenny is the registered manager of Eldra Court. He was registered in June 2007 but has carrying out the duties of a manager since the former manager left his post in October 2006. Mr Kenny is very experienced in the provision of care for people with learning disabilities. He is currently studying Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 24 for an Open University Degree in ‘Health and Social Care’ and will start working towards gaining his Registered Managers Award in September 2008. Mr Kenny was seen to interact very well with the people who use the service and feedback from staff surveys indicates that he is a supportive and approachable manager. The home still has not developed effective quality assurance and quality monitoring systems to enable an annual development plan based on a cycle of planning, action and review, reflecting aims and outcomes for the people who use the service. There are, however, systems in place, including staff and residents meetings, the key worker system and the use of surveys to gain feedback from relatives and professional people involved with the residents. In addition to this the residents care plans and the use or ‘goals’ provides evidence that the service is developmental in its approach to the provision of care and that the people who use the service are being encouraged to use and build on their existing skills. Reports were seen to provide evidence that regular monthly visits are being carried out on behalf of the registered service providers. The AQAA identifies that most of the required and recommended written policies and procedures are in place and that they were reviewed in January 2008. It is understood that a complete review of all policies and procedures by the service providers is planned. The existing policies and procedures are kept accessible to the staff in a file in the office. The staff are encouraged to read and familiarise themselves with these. The AQAA identified that the servicing of portable electrical equipment, fire detection and fighting equipment, soiled waste disposal systems, heating equipment and gas appliances are up to date. The registered manager said that the staff and residents have regular fire drills and could now evacuate the premises in less than a minute. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 25 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 4 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 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 X 3 X 2 X X 3 X Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 26 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 Requirement The registered persons must ensure that the recording, handling and administration of medicines are carried out safely. Timescale for action 11/09/08 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 YA1 Good Practice Recommendations The Service User’s Guides should be revised to include the amount and method of payment of fees. A standard form of contract for the provision of services and facilities by the registered provider to the resident. And, a copy of the agreement specifying the arrangements made for the provision of accommodation and personal care between the contracting authorities and the service provider. All records should be signed and dated by the person compiling them and, wherever practical, by the resident that the record is kept for. The registered manager should complete his Registered Managers Award. DS0000064403.V366563.R04.S.doc Version 5.2 Page 27 2. YA7 3. YA37 Eldra Court 4. YA39 The registered persons should produce an annual development plan for the home, based on a systematic cycle of planning, action and review, reflecting aims and outcomes for the people who use the service. Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Eldra Court DS0000064403.V366563.R04.S.doc Version 5.2 Page 29 - 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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