Inspection on 30/05/06 for 1 Cauldon Place

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Cauldon Place 27/02/08

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 Ms Wendy Jones Key Unannounced Inspection 30 May 2006 10:00 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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.V293458.R01.S.doc Version 5.1 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.V293458.R01.S.doc Version 5.1 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 Mr David Vincent Mr Mark Austin 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.V293458.R01.S.doc Version 5.1 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 23rd November 2005 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. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of the Cauldon Place Residential Care Home, carried out over a period of two days, from the 30th May-31st May 2006. The inspection methodology included pre inspection details; service user, and relative questionnaires, discussion with social workers and the GP; inspection of the environment; discussion with service user and the manager; interviews of staff; inspection of care records and other documents pertinent to the inspection process. Fees for care and accommodation vary dependent on the level of need, some service users were funded for 1:1 or more staffing. At the time of the visit, the home was accommodating 18 service users and ages ranged from 19 to 55 years. The inspection focused on flat 4, flat 3, and flat 1. Flat 1 provided accommodation for one young person on a 1:1 basis. Flat 3 provided accommodation for 5 service users and 1 service user who resided in apartment 3. Flat 4 accommodated 5 service users and 1 in Flat 4. Dependency of service users was described as 3 high, 6 medium and 9 of low dependency, 3 service users were described in the pre inspection information as exhibiting extreme behaviour, 2 had a hearing impairment and 1 was visually impaired. 3 service users had specialist communication needs, 1 service user had English as a second language, 2 service users had mental health needs. A number of service users had autistic tendencies. Since the last inspection the provider has met with the Commission for Social Care Inspection to discuss areas of concern that had occurred during that period. This inspection included assessment of compliance with those requirements made. Changes in the home since the last visit included new heating and radiators, changes to the gardens and some redecoration and re carpeting in the flats. The service has plans for further developing the home and to change two ground floor bedrooms into a single occupancy flat. This inspection did not include a detailed examination of the environment. What the service does well: The service provides service users with opportunities to live as independently as possible, dependent on the level of need and ability. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 6 Comments received from relatives, social workers, and health professionals included “General satisfaction” “Satisfied with placement” “Very happy with service, issues at last review appear to be resolved.” “satisfied with the overall care” “complimentary about staff.” 3 service users provided feedback via questionnaires saying, “Like staff and care,” “Like living at the home,” “Satisfied.” “feels treated well” The service outcomes for this inspection were good or adequate. What has improved since the last inspection? What they could do better: Service users who completed the survey’s returned prior to this visit made some positive comments as previously stated they, also made some negative comments such as “Doesn’t like living at the home,” “only sometimes likes the food,” “ some times feels safe and feels treated well”, “would like more suitable activities and more choice in food,” Health professionals also made some positive comments regarding the service but also raised some areas of concern “staff who accompany service users, do not always know much about them.” “Concerns about value base of some staff.” The pen pictures for service users must be written with them and if written in the first person, be representative of the service users views. The manager must resolve the issues raised by one service user and if necessary arrange a review with a social worker. The agenda’s of service users meetings should be given further thought. Recruitment records must include all items identified in regulation. Vulnerable adults, adult abuse and autism training must be provided. Environmental issues identified during this inspection must be resolved. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 7 Review the medication policy and procedure to ensure it reflects current practice. 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. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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.V293458.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5. The quality outcome of these standards was good. This judgement was based upon the examination of records and from a visit to the home. Each of the service users had a service user guide in their files; assessment information was good. EVIDENCE: A Statement of Purpose and Service user guide had been produced by the organisation. Discussion with service users indicated that some were aware of the contents of the service user guide and the philosophy and aims of the service. Since the last inspection three service users have been admitted, and 6 discharged, this movement of service users is in keeping with the service philosophy of promoting independence. The format for pre admission assessment of prospective service users was comprehensive. Arrangements were made for prospective service users to visit the home prior to making a decision to move in for the majority. The manager identified a problem in accomplishing this for one service user who was unusually admitted as an emergency placement. Contracts outlining the terms and conditions of residency were included in service users records. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The quality outcome of this standard was good. This judgement was based upon the examination of records, discussion with service users and staff and from a visit to the home. Care plans were in place to address the assessed needs of service users, there was evidence of some service user involvement in decision making. EVIDENCE: Each service user 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 service user, written in the first person. Concerns were expressed about the negative tone of a pen picture for one service user, it was suggested that a review should be undertaken of the pen pictures to ensure that service users are fully involved in writing the pen pictures and agree with the description recorded. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 11 Samples of care plans and records were seen with the service users when possible. Individuals confirmed that they had been involved in care planning, others were unsure. Some care plans showed that service users had signed records confirming involvement and agreement. There was evidence that care plans had been reviewed. One service user in residence was of the Muslim faith, the care plan provided detailed information relating to the individuals culture and religious belief 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. Risk assessments identified the level of risk and the action staff should take to support service users to minimise the risk. There was evidence of negotiation between some service users and staff relating to independent time, out of the home. Risk assessments were also subject to review, there was evidence that social workers had been consulted. One service user was not happy about a risk assessment that he felt restricted his independence, it was suggested that the manager discussed the levels of risk for him and others and if necessary liaise with the social worker and involve independent advocacy services to resolve the his concerns. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 17, The quality outcome for this standard was adequate. This judgement was based upon information provided and the visit to the home. The service supported service users to access recreational and social opportunities, more attention should be given to accessing socially valued activities for some service users. EVIDENCE: Information in the pre inspection information included service user comments that they would like more varied activities to engage in. Some service users had a full social, recreational life outside of the home others were dependent on support from staff. During this visit, there was evidence that service users 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 service users have work placement opportunities. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 13 There was also evidence from the records and from discussion with service users that they went to local football matches, went ten pin bowling and to the cinemas, out to pubs and for meals. Some service users who can independently access local community facilities and are encouraged to do so. It is recommended that service users are supported to access more integrated rather than specialist or segregated activities where possible. With reference to a service user of the Muslim faith information was in place in relation to religious festivals and there was evidence that the individual was able to participate in these festivals. It is recommend that more emphasis should be focused on staff training in relation to diversity. There was evidence that service users were supported to keep in touch with relatives and friends, via telephone calls, letters or visits. In one example the service provided transport home for the service user every week an arrangement that had been agreed in consultation with the family. Food stocks in three flats were seen and appeared to be adequate, service users were generally satisfied with the meal choices. Weekly menu planning meetings were held in each of the flats and each service user is able to contribute to the menu. Because of this the choice for each day is limited, although some service users said they could choose something else, some weren’t sure if they could. In the pre inspection information one service user had said that he/she sometimes likes the food. It was recommended that all service users are informed that they can have an alternative to the main meal, or the menu’s should reflect this. A healthy eating regime had been adopted by Flat 4. Although the service users understood the rational for this, they did not always make healthy choices, this caused some conflict. It was recommended that service users were supported to make healthy choices if appropriate but staff must also respect the service users rights to make other choices. There was some discussion about the food budget, some staff felt that the budget was limited and therefore limited the food choices and quality of service users, by limiting the shops they could use. This was subject to some discussion at previous inspections and efforts had been made to undertake and audit of food provision and to produce guidance for staff in food preparation and cooking. These matters were discussed with the manager who stated that if the allocated food budgets were used there, was a petty cash fund that could be used. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 14 The examination of the menus and food in storage identified a positive outcome in the purchasing of provisions with reference to a service user of Muslim faith, special dietary requirements in relation to his cultural/religious faith. Discussions with one staff member confirmed family involvement and support to meet the cultural and religious needs of the service user. Another service user required a high fat diet, the care plan incorporated information relating to the individuals dietary needs. A diet diary was also implemented; it is recommended that the diary should be appropriately dated. A fluid intake chart was also in operation, the care plan identified the support and assistance required to ensure that the service user maintained a health diet. Discussions with the Care Manager confirmed that there was currently no dietician intervention. 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. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. The quality outcome of these standards were adequate. This judgement was based upon information provide and a visit to the home. The personal and health care needs of service users were met, providing service users with a satisfactory service. EVIDENCE: Service users 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. 1 service user requires assistance with his continence management, 2 require assistance with dressing and undressing, 1 requires help or supervision with mealtimes, 7 require help with washing and bathing. Information in the pre inspection information indicated that the health care needs of service users were satisfactorily met. Records showed that service users attended regular health appointments such as dental, chiropody and opticians. There was evidence that service users were supported to attend hospital and GP appointments, during the pre inspection information collation one health professional had raised concern about the staff accompanying service user who where not able to answer health questions about the individual. It was suggested that where possible key staff only, accompany service users to this type of appointment. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 16 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. 18 staff have received training in the safe administration of medication, each of the floors had their 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. Matters arising included the need to review the policy and procedure for the administration of medication last recorded for 2003, to ensure that it reflects current practice. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality outcome for these standards was adequate. This judgement was based upon information provided and a visit to the home. Complaints information was provided to service users and any issues investigated and resolved. EVIDENCE: Since the last inspection the Commission for Social Care Inspection has received 2 formal complaints about the service and there has been 3 Vulnerable Adults referrals. The outcome of 1 complaint was not substantiated, the outcome of the second was inconclusive. There had been two other incidents reported during the period since the last inspection. In the pre inspection information the manager stated there had been 15 complaints referred to the home, 8 of which had been substantiated in the 12 month period prior to the inspection. Record of complaints and how they were managed were seen during the visit. 3 relatives returned feedback forms, they made some positive comments about the care provided and identified areas of concern that were discussed with the manager for action. Concerns included “Doesn’t know about the complaints procedure or inspection reports,” “ concerned about phone system, doesn’t think there are enough staff,” “ concerned that a relative may have to leave the service to live semi independently.” 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 18 1 service user was not happy with aspects of the service, other service users gave positive feedback and stated that they knew how to complain and who to go to. All staff must receive training in recognising and reporting adult abuse. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 The quality outcome for these standards was adequate. This judgement was based upon the information provided and a visit to the home. The environment required further improvement in some areas for the benefit of service users. EVIDENCE: This inspection did not include a detailed inspection of the environment. Information from the pre inspection information and from discussion indicated that some redecoration and refurbishment of flats had taken place; work to improve the heating had also been undertaken. Matters arising were from the outcome of discussion with service users or from general observation. The home is divided into 8 living areas, each with its own communal facilities, single bedrooms, some have en-suite, own entrance and exit. In flat four, a service user identified that the vacuum cleaner had broken down and one service user queried why her 4th floor window and restrictors fitted the health and safety reasons were explained. In one bedroom the carpet would benefit from cleaning or replacing. Bathrooms and shower rooms, while functional would benefit from more homely touches to make them more welcoming for service users. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 20 Fire safety matters included the door to one flat that didn’t close too properly, work men were in the home during the period of the inspection to resolve any areas of concern. Some service users have been provided with a swipe key to their flat and the main door in efforts to promote independence. All service users have access to a bedroom door key if they choose to have one. The provider has more plans to develop the service and will be forwarding plans to the Commission for Social Care Inspection. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 36. The quality outcome for these standards was adequate. This judgement was based on the information provided and a visit to the home. Staff training deficits must be resolved to ensure that the quality of care delivery is reflective of the needs of service users and in keeping with the service philosophy and aims. EVIDENCE: Staff recruitment had improved with 9 staff vacancies at this visit, less than at the last inspection. Staff numbers were being maintained by staff overtime or use of agency staff although the agency usage had also decreased since the last inspection. In the eight weeks before the inspection 692 hours have been provided from the two care agencies used. Six staff had left since the last inspection, one of whom had been dismissed. Four waking night staff were deployed, one for each floor. Each of the floors had their own staff team during the day a total of 1021 hours were deployed per week. The numbers of NVQ level 2 trained staff were poor with only seven with the qualification, the manager and the Human Resources manager stated that 18 staff were undertaking the training, the service currently employs 40 care staff. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 22 Planned training included Autism, health and safety, infection control, epilepsy, food hygiene, first aid, health action plans, Non Crisis Intervention (NCI). Systems were in place for staff supervision and there was evidence provided from discussion that individual supervisions was being carried out. Recruitment records showed that there was satisfactory recruitment practice, out of five records seen there was one that did not comply with regulation. A requirement relating to this has been made. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality outcome for these standards was adequate. This judgement was based upon information provided and a visit to the home EVIDENCE: The manager has not yet been interviewed or registered by the Commission for Social Care Inspection. She has submitted an application and an interview date is planned. The manager had introduced a team of senior staff to support and supervise the staff. The provider stated that he had produced a new format for the Regulation 26 reports linked to the National Minimum Standards and would be forwarding them to the Commission for Social Care Inspection on a monthly basis. Since the last inspection the reports have not been received on a regular basis. The organisation has recruited a Quality assessor, who will be responsible for reporting on the quality outcomes for service users, it is hoped that this information will inform the Annual Development plan for the service. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 24 A copy of the Quality assessment document showed that it was linked to the national minimum standards and was a suitable format to use. Information in the pre inspection information stated that servicing of equipment in the home had been undertaken regularly. Fire drills and fire training had been carried out. The fire alarm system was to be replaced following this visit. Policies and procedures were available in the managers office and in each care office, relevant policies and procedures had been produced in a user-friendly format for the benefit of service users. The pre inspection information indicated that most policies and procedures had been reviewed in June 2005. The certificate of registration does not accurately reflect the service, as the named care manager is no longer employed at the home. The service user categories, were discussed with the new manager, this was identified at the last inspection and will be discussed with the provider. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 1 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 2 15 2 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 X 2 X X 3 X 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA39 Regulation 26 Requirement Regulation 26 visits to be carried out monthly and reports made available in the home and to the CSCI.(previous timescale not met 20 February 2005)(04/06/05) The registered person must liaise with social workers, advocates to ensure that service users wishes are met. The registered person must ensure that representatives of service users know how to complain. The registered person must ensure that all areas of the home are clean. The recruitment records of staff must contain, photographs, cope of birth certificates, two written references. Staff must receive training in the protection of service users, recognising and reporting abuse. Staff must receives autism training and any other training relevant to the needs of service users including values based training. Timescale for action 30/08/06 4 YA9 13 30/08/06 5 YA22 22 30/08/06 4 5 YA24 YA34 16 17, schedule 2 13, 18 18 30/09/06 30/09/06 6 7 YA23 YA35 30/09/06 30/09/06 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 27 8 YA24 23 Doors identified as fire doors must close properly into the rebate. 04/06/06 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 3 4 5 6 7 8 Refer to Standard YA9 YA6 YA17 YA17 YA19 YA14 YA27 YA20 Good Practice Recommendations Make referrals for independent advocacy services for individuals, to support them to make decisions relating to their lifestyles. It is recommend that more emphasis should be focused on staff training in relation to diversity. Service users should be supported to make informed decisions about meal choice. Alternatives to the main meal choice should be provided. Service users should be accompanied to health appointments by key workers or key staff. Further efforts should be made to integrate service user in activities that are socially valued. Further efforts should be made to make the bathrooms and shower rooms more homely and welcoming. Medication policy and procedure to be reviewed. 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 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 1 Cauldon Place DS0000008207.V293458.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!