Inspection on 27/02/08 for 1 Cauldon Place

This inspection was carried out on 27th February 2008.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Cauldon Place 30/05/06

1 Cauldon Place 04/05/05

1 Cauldon Place 19/01/05

1 Cauldon Place 18/08/04

1 Cauldon Place 21/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 1 Cauldon Place 1 Caledonia Road Shelton Stoke-on-Trent Staffordshire ST4 2DG Lead Inspector Pam Grace Key Unannounced Inspection 27th February 2008 09:00 1 Cauldon Place DS0000008207.V345206.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 1 Cauldon Place DS0000008207.V345206.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. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Cauldon Place Address 1 Caledonia Road Shelton Stoke-on-Trent Staffordshire ST4 2DG 01782 275770 01782 275777 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) Richmond Care Homes Limited Kay Trow Care Home 25 Category(ies) of Learning disability (25), Mental disorder, registration, with number excluding learning disability or dementia (25) of places 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 LD, aged 16-18 years The 2nd floor of Caledonia House cannot be used as service user accommodation 30th May 2006 Date of last inspection Brief Description of the Service: Cauldon Place is registered to care for younger adults with learning disabilities and mental health needs. The home is part of the Richmond Care Group, which operates two other homes and a day college in the Hanley area. The home is situated on a main bus route from Stoke to Hanley town centre and is adjacent to Stoke-on-Trent college. The accommodation was formerly used as student accommodation and is in keeping with the neighbouring student facilities. A large car park is available to the rear of the home. The accommodation is organised into small self- contained flats for one person or groups of up to six. Fees are assessed on an individual basis, and will be reviewed annually. 1 Cauldon Place DS0000008207.V345206.R01.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 stars. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection, carried out over a period of one day. The inspection had been planned with information gathered from the CSCI database, and the Annual Quality Assurance Assessment document, which had been completed by the care manager. 6 “Have Your Say” surveys were received from residents at the home. They included comments such as “some carpets need cleaning”, “I don’t get enough days out”, “the home needs decorating”, “my door creaks” and “I can’t always have headache tablets”. There were also positive verbal comments received by the inspector during the visit. These comments were highlighted and discussed with the care manager during the inspection visit. The key National Minimum Standards for Adults (18 – 65) were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff and residents. A tour of the environment was also undertaken. At the end of the inspection, feedback was given to the care manager, outlining the overall findings of the inspection, and the requirements and recommendations made. Residents spoken with were very positive about the care they were receiving. Residents who had communication and specialist behavioural needs appeared well cared for, and were happy in their surroundings. General observations were undertaken during the course of the inspection in relation to staff conduct and interaction with residents. There had been one complaint made to the Commission for Social Care Inspection (CSCI), which was also referred to Social Services under the Safeguarding Protocol since the previous inspection. This had been dealt with in a timely way under the home’s complaints procedure by the care manager, and had been upheld. Fees for care and accommodation are available upon request, and vary, dependent on the individual’s level of need, some residents were funded for 1:1 or more staffing. At the time of the visit, the home was accommodating 18 residents, and ages ranged from 19 to 55 years. Accommodation is divided into flats. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 6 The residents’ dependency levels were described as high, medium and low dependency. The care manager confirmed during discussion that residents’ needs included the management of challenging behaviours, hearing impairment, visual impairment, communication needs and mental health needs. A number of residents also had autistic tendencies. The service has plans for further developing the home and to change two ground floor bedrooms into a single occupancy flat. What the service does well: The service provides residents with opportunities to live as independently as possible, dependent on their level of need and ability. Health care awareness was evident, with the importance of any changes in health status and mental health, being continually monitored by appropriately trained, caring and diligent staff. Staff demonstrated great respect for residents, and residents were addressed in an appropriate manner. Discussions with staff were positive, and showed a clear determination that they belong to a committed team. Residents spoken with during the inspection visit were very positive about the care that they were receiving. Residents who had communication and behavioural needs appeared well cared for, and appeared to be happy and comfortable in their surroundings. Residents spoken with said that they could choose what they wanted to do. This was evidenced through discussion and inspection of the records. Relatives are encouraged to participate and contribute towards residents’ reviews. Residents have a choice, and are encouraged to have a say in how their service is run, as well as in pursuing their own interests and hobbies. Residents have a choice in relation to the decoration of their own bedroom. Furnishings in those rooms were comfortable and homely. Staffing levels have been maintained. The home was clean and warm. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 7 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. 1 Cauldon Place DS0000008207.V345206.R01.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 1 Cauldon Place DS0000008207.V345206.R01.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, and 5 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home, which will meet their needs. EVIDENCE: Residents and staff spoken with, confirmed that residents had received information about the home, and had visited the home and met staff from the home prior to the move. A Statement of Purpose and Service user guide had been produced by the organisation. There had been no changes in regard to the Statement of Purpose or Service User Guide. Both of these documents had been examined in detail at the previous inspection. Assessment information in the individual files seen was detailed and there was evidence of professional and or social worker assessments. Each resident had a copy of the Service User Guide in their care files. The terms and conditions of residency were also contained in the Service User Guide. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 10 1 Cauldon Place DS0000008207.V345206.R01.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): 6,7,8,9 and 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The care manager confirmed that each resident had a 24 hour plan of care, which gave an account of their preferred routine from waking to retiring there was also a pen picture of each resident, written in the first person. Samples of care plans and records seen confirmed the above, and that residents had been involved in care planning, and wherever possible residents had signed their own records confirming involvement and agreement. There was also evidence that care plans had been reviewed. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 12 The inspector noted that residents’ cultural and religious beliefs are well supported by the home. An example of this was highlighted, a resident of the Muslim faith, had a care plan which provided detailed information relating to the individual’s cultural and religious beliefs, and also provided information relating to the degree of support and assistance required, to enable the individual to maintain a lifestyle in relation to his cultural background. Information relating to the Muslim faith was also incorporated within the individual’s records. This included what foods to buy and cook, and where to buy the food. Risk assessments identified the level of risk and the action that staff should take to support residents, in order to minimise the risk. There was evidence of negotiation between some residents and staff relating to independent time, out of the home. Risk assessments were also subject to review, there was also evidence of social work involvement. This visit included discussions with 6 residents. All residents spoken with were aware of who their key worker was. Most residents were aware that their care plans were stored securely in the office and confirmed that their care plans were reviewed regularly, i.e. monthly, this was also evidenced by examining 3 care plan records. The ethos of the home encourages person centred practice, and enables residents to make their own decisions, staff were observed addressing and encouraging residents in an appropriate and valuing manner. Residents spoken with said “ I can please myself,” “ Staff help me when I need it,” “ I can use the kitchen when I want to, and staff help me to cook and to make cakes”. Residents confirmed that they have meetings on a regular basis to discuss any problems, plans for future activities and events, menu planning and routines. This was evidenced from the records of the meetings that were available. Residents were very eager to talk to the inspector about their trips out, cooking and baking, and crafts. The home is situated near community facilities such as shops, restaurants and pubs. Some residents said they were able to cook their own meals. All residents spoken with agreed that they do enjoy taking part in cooking their own meals. However, this depended upon their abilities and their risk assessment. Residents’ monies are checked daily. This information is passed to the staff on the next shift and signed for, to confirm accuracy. The manager or senior staff carries out a monthly quality audit to ensure that the sums recorded accurately reflect the amount of money kept on behalf of residents. 1 Cauldon Place DS0000008207.V345206.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): 11,12,13,14,15,16, and 17 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and are supported to develop their life skills. Social, educational cultural and recreational facilities need to have a broader focus, in order to meet individual’s expectations. EVIDENCE: Some residents were relatively independent in their day-to-day lives. They were supported in accessing the community, and they said that they were able to make decisions about what they did during the day. Residents and staff confirmed that residents were supported to attend a range of activities outside of the home. The range included attendance at the Richmond group day centre, visits to the local shops, a small number of residents have work placement opportunities. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 14 There was also evidence from the records and from discussion with residents that they went to local football matches, to ten-pin bowling and to the cinemas, out to pubs and for meals. The home is situated near to community facilities such as shops, pubs, and restaurants. During the inspection one resident had just returned from shopping, and another resident had been supported with preparing and cooking lunch in the kitchen. Meal times were fairly flexible, dependent on the routines and activities of service users. Each flat or apartment has it’s own kitchen to which service users have free access. Residents were observed making choices about the meals they wanted, preparing and cooking them. The inspector was pleased to note the home’s written guide, which enables residents to choose, prepare and cook meals using pictorial guides, and recipes. This would all be done with support from staff, and would be dependent upon the residents’ own abilities. The examination of menus, and discussion with residents identified that meals provided were wholesome varied and well balanced. The service met the standards of basic food hygiene, and records in relation to the fridge/ freezer and hot food temperatures were examined, and were up to date and correct. General observations throughout the course of the inspection and discussions with residents confirmed that staff were respectful of residents’ privacy and would knock on bedroom doors prior to entering. Residents confirmed that their letters were distributed to them unopened. Residents who have higher levels of need, and or specialist communication needs have detailed daily programmes. Residents would be supported by staff on a 1:1 or 2:1 basis, dependent upon their level of need. Programmes are reviewed and updated regularly. 1 Cauldon Place DS0000008207.V345206.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): 18,19,20 and 21 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Residents spoken with knew who their key workers were and stated that they had good relationships. Staff were observed to knock and wait to be invited into service users bedrooms. Records seen showed that residents attended regular health appointments such as GP, dental, chiropody and opticians. Personal aids and equipment are available to support both resident and staff in daily living. Other specialist health input is provided for each individual, dependent on need, including psychology, psychiatry, behavioural services, community learning disability nurse, physiotherapy. A health care facilitator had been providing staff with training in Health action plans. The care manager and staff spoken with confirmed that they had received training in the safe administration of medication. Each of the flats had their 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 16 own medication cupboards and information. A sample of the medication storage and records were seen during this visit. There was evidence of good record keeping and practice seen. The inspector discussed the outcome of a complaint, which, at the time of the complaint, had highlighted the need for medication procedures to be reviewed. The care manager confirmed that this had been undertaken, and that procedures in relation to medication that is taken out of the home by residents, for example when the resident is visiting and or staying with relatives, have been reviewed and improved upon. Care staff work to a consistent standard and constantly monitor pain, distress and other symptoms to ensure individuals receive the care they need. 1 Cauldon Place DS0000008207.V345206.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): 22 and 23 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. However, staff must receive update and refresher training in regard to the Protection of Vulnerable Adults (POVA). EVIDENCE: The home has a clear complaints policy and procedure. A copy of the procedure was displayed in the home. The inspector discussed the outcome of a complaint, which, at the time of the complaint, had highlighted the need for medication procedures to be reviewed. The care manager confirmed that this had been undertaken, and that procedures in relation to medication that is taken out of the home by residents, for example when the resident is visiting and or staying with relatives, have been reviewed and improved upon. The Commission for Social Care Inspection (CSCI) had received 1 complaint, which was also referred to Social Services under the Safeguarding (POVA) Protocol, since the previous inspection. That complaint/referral had been upheld, and amicably resolved by the care manager. The inspector examined 4 staff recruitment files, and spoke with 4 staff members. One file for a new staff member was awaiting a CRB Police Check, and a second reference. This was highlighted at the time, and discussed with the care manager. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 18 All 4 files evidenced that a uniform and robust recruitment procedure is in place at the home. The care manager confirmed that those checks would always be undertaken prior to staff’s commencement of employment. Residents spoken with confirmed that they would know who to go to if they had any concerns. Their comments included “ I can speak to my key-worker”, “I can go and knock on the manager’s office door”. Independent advocacy services were highlighted and discussed in relation to the Mental Capacity Act 2005. The inspector recommended that those services should be sought as appropriate for individual residents, and that staff should also receive appropriate training. However, it was acknowledged that the service does also support residents with self-advocacy. The evidence of this inspection confirmed that a number of residents at the home are well able to express themselves. 4 staff were spoken with during this visit. They gave satisfactory responses to questions about the Protection of Vulnerable adult/Safeguarding issues, and gave accounts of and examples where they had supported residents. However, the training matrix provided to CSCI evidenced that staff had not received update and or refresher training in this area. The score of 2 for this standard reflects this shortfall. 1 Cauldon Place DS0000008207.V345206.R01.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): 24,25,28,29 and 30 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe and comfortable environment, which encourages independence. However, there are many areas of the home that need maintaining, re-decoration and or refurbishment. EVIDENCE: The standard of the environment within this home is adequate, providing residents with a clean, comfortable and homely place to live. Specialist aids and adaptations were in place to assist and promote residents’ independence. This inspection included a tour of the building, including all flats. The home is divided into 8 flats. Each flat has it’s own kitchen, lounge and dining area. Not all bedrooms have en-suite facilities. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 20 Information contained in the AQAA document confirmed that the home needs to develop a rolling programme of maintenance. Discussion with the care manager indicated that some redecoration and refurbishment of flats had already taken place; and work to improve the heating had also been undertaken. However, there are still many areas that need maintaining, redecorating and or refurbishing. One radiator cover was loose and needed fixing to the wall, another radiator cover had a wire mesh which had separated from the cover and could cause injury due to it having sharp edges. One wall in a resident’s lounge needed plasterwork renewing. Some areas needed re-carpeting. These were highlighted during the visit and discussed with the care manager. The scoring of 2 for most of these standards reflects these shortfalls. One shower had a strong smell of dampness. The extractor fan did not work properly. This was also highlighted and discussed with the care manager. Some residents have been provided with a swipe key to their flat and the main door in efforts to promote independence. All residents have access to a bedroom door key if they choose to have one. A sample of bedrooms showed that they were adequately furnished and residents have been supported to personalise them, creating a lovely ambience. Residents gave positive comment about their home. 1 Cauldon Place DS0000008207.V345206.R01.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): 32,33, 34 and 35 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home must be trained, skilled and in sufficient numbers to support the people who use the service. in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: There was a total of 42 staff employed at the home. Five waking night staff were deployed, one for each floor. Each of the floors had their own staff team during the day. Agency staff are utilised as and when required. The care manager confirmed in the AQAA document that the numbers of NVQ level 2 trained staff are now at 57 . This exceeds the National Minimum Standard. Systems were in place for staff supervision and there was evidence provided from discussion that individual staff supervision was being carried out. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 22 Recruitment records showed that there was a satisfactory recruitment procedure in place, out of four records seen there was one in relation to a newly recruited member of staff that was awaiting a CRB check and a second reference. This was highlighted to the care manager at the time. Staffing levels for each unit were maintained at a minimum of 4 care staff per shift, but additional staff were provided to support residents for specific events or occasions. Positive comments were received from staff spoken with. However, the staff training matrix provided to CSCI confirmed that staff needed update and refresher training in regard to Food Hygiene, the Protection of Vulnerable Adults (POVA), training in regard to the Mental Capacity Act 2005, and Autism training. POVA and Autism training were identified at the previous inspection, and the inspector has asked that CSCI is notified when this training is undertaken. Fire training records were up to date, and documented. 1 Cauldon Place DS0000008207.V345206.R01.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): 37,38,39 and 42 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: Since the previous inspection, the care manager has been registered by the Commission for Social Care Inspection. She is ably supported by two Unit Coordinators, and 4 Senior Support Workers. Monthly Management meetings have been established with the provider, since the previous inspection, ensuring a strong line of communication with the provider in regard to the day to day running and management of the home. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 24 There needs to be a planned and rolling programme of maintenance, redecoration and refurbishment of the home. A copy of that programme plan needs to be forwarded to CSCI. Policies and procedures were available in the care manager’s office and in each care office, relevant policies and procedures had been produced in a userfriendly format for the benefit of residents. Residents are openly encouraged by staff to participate in, and contribute towards decision making, in the general running of the home. Care plans seen were clear, comprehensive and up to date. With relevant risk assessments undertaken and reviewed on a regular and needs led basis. There had been one complaint received by CSCI, which was also a Safeguarding referral made to Social Services, since the previous inspection. This had been upheld and amicably resolved. Staff recruitment files reflected that a uniform and robust recruitment procedure is in place at the home. The inspector examined 4 staff recruitment files, and spoke with 4 staff members. Staff spoken with and records examined confirmed that at the time of this inspection visit, there were adequate staffing levels to meet residents’ needs. There was a positive commitment from the staff group to meet the needs of residents. With reference to staff training, staff spoken with and records seen confirmed that staff are accessing NVQ level 2 and level 3 training, and that approximately 57 of staff had achieved their NVQ level 2 or above. Fire training had been undertaken, moving and handling, health and safety and first aid. Staff need training in regard to Food Hygiene, Protection of Vulnerable Adults, Autism and the Mental Capacity Act. 6 x “Have Your Say “ feedback documents were received by CSCI from residents at the home. Comments received were discussed with the care manager during the visit. The organisation has put in place a quality audit system and employs some one to visit each of the homes to audit against a particular standard periodically. 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 25 The Annual Quality Assurance Assessment document (AQAA) that the Commission for Social Care Inspection (CSCI) sends out for completion by the care manager. Was not comprehensively completed by the care manager. There was not enough information provided in regard to the Standards outcome areas. This will be monitored at the next inspection. 1 Cauldon Place DS0000008207.V345206.R01.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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 X X 3 X 1 Cauldon Place DS0000008207.V345206.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18 Requirement Staff must receive training in regard to Autism, and any other training relevant to the needs of service users. Previous timescale not met 30/09/06 Staff must receive training in regard to Food Hygiene. Staff must receive training in the protection of service users from abuse. Previous timescale not met 30/09/06 Timescale for action 30/06/08 2. 3. YA35 YA23 18 13,18 30/06/08 30/06/08 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 YA24 Good Practice Recommendations There should be a written plan in relation to a rolling programme of maintenance, redecoration and refurbishment of the home. A copy of which, should be forwarded to CSCI. Staff should receive training and information in regard to the Mental Capacity Act 2005. DS0000008207.V345206.R01.S.doc Version 5.2 Page 28 2. YA35 1 Cauldon Place Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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