Earlsdon Park Village, operated by The ExtraCare Charitable Trust, was rated Good across all five key questions at its January 2020 inspection, with 52 people receiving personal care in a purpose-built extra care housing setting. Minor record-keeping gaps around Mental Capacity Act documentation and medicine administration records were identified and addressed during the inspection visit.
Concerns (3)
minor
Medication management
: “Medicine records did not always contain clear explanations when medicines had not been administered. The code "0" was being used in place of a signature but this was not always defined.”
minorRecord keeping: “We found some records lacked information. This included information about best interest decisions made. However, records needing improvement were addressed during the inspection visit.”
minorConsent / capacity: “One person did have some restrictions placed on them, but records regarding the persons capacity and the process followed to confirm this was in their best interests were not clear.”
Strengths
· People felt safe and staff were kind, respectful and knew people's individual needs well
· Sufficient staffing levels with safe recruitment procedures in place
· Staff completed regular ongoing training including safeguarding, MCA, infection control and medicines
· Wellbeing clinics provided by an onsite nurse with access to GP and specialist services
· Quality monitoring systems in place with actions taken to address shortfalls following audits
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely care; Supporting people to live healthier livesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
Earlsdon Park Village received a Good rating across all five key questions at its June 2017 inspection, with people and relatives consistently praising caring, knowledgeable staff and a well-supported management team. Minor governance shortfalls were identified around late CQC notifications and office-to-staff communication, both of which were being actively addressed by the registered manager.
Concerns (2)
moderateGovernance: “not all relevant notifications had been submitted to CQC...notifications had not been sent during a period of staff changes.”
minorCommunication with families: “some examples of poor communication between the office administration and care staff...care calls had been cancelled by the person but staff had not been informed.”
Strengths
· People felt safe and staff demonstrated good knowledge of safeguarding and individual risk management
· Robust medicines management with staff training, competency checks and refresher training for errors
· Strong induction programme praised by staff as thorough, with effective shadowing and ongoing supervision
· Staff treated people with dignity, respect and kindness, going above and beyond to support independence
· Care plans were person-centred, reviewed regularly, and adapted for individual needs including language translations