Inspection on 04/05/05 for 1 Cauldon Place

This inspection was carried out on 4th May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

1 Cauldon Place 27/02/08

1 Cauldon Place 30/05/06

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 Cauldon Place 1 Caledonia Road Shelton Stoke-on-Trent ST4 2DG Lead Inspector Wendy Jones Unannounced 04 May 2005 09:30 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 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 Stationary 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. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cauldon Place Address 1 Caledonia Road Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01782 263704 01782 263704 Richmond Care Homes Limited Mr James Cullen CRH 25 Category(ies) of Learning Disabilities registration, with number of places Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 LD, aged 16 - 18 years The 2nd floor of Caledonia House cannot be used as service user accommodation Date of last inspection 19/20 January 2005 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. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried on the 04th May 2005. The manager was available for part of the inspection. Occupancy was reported to be 21 service users. The inspection was carried out on flat 3 and flat 4; from care and other records; observation of the environment; discussion with staff and conversation with service users. The majority of service users were out of the home during the visit. Service users accommodation and the home generally, were observed to be clean and maintained to a good standard. Since the last inspection a flat has been fully refurbished to a very high standard to accommodate two service users, in the effort to provide an environment more conducive to promoting independence. From the sample of care records the service demonstrated a good standard of assessment, care planning, and risk assessment with evidence of regular reviews. The service had addressed the majority of the requirements from the last inspection. Outstanding matters were discussed and have been included in the requirements for this report. A staff recruitment drive since the last inspection had resulted in 10 new staff employed of varying experience, markedly reducing the number of agency staff used by the service. Also a programme of training and induction had been undertaken to address the deficits identified in the previous report. The manager has yet to be approved by the CSCI, arrangements are being made to complete the registration process. What the service does well: The service endeavours to promote service user independence within a framework of good assessments of need, care planning and risk assessment. Principles of care associated with Learning Disability services are known and adhered to. The provider has consistently demonstrated a willingness to make changes to the service for the benefit of service users, following discussion or representation by service users and staff. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 6 Staff support service users to access suitable, leisure, recreational and occupational opportunities. The service promptly records, acts on and reports any incidents or accidents that have occurred in the home. 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. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The homes Statement of Purpose and Service User Guide were of a good standard, providing service users and prospective service users with details of the services the home provides, enabling them to make an informed decision about admission to be made. EVIDENCE: The service had reviewed the Statement of Purpose since the last inspection, and had ensured that all service users were provided with a copy of the Service User Guide. A copy of the revised Statement of Purpose was seen during this visit. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 9 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 standard(s) 7,8,9 The standard of individual risk assessment was high, providing staff with the necessary information to responsibly promote service user independence in all aspects of their daily life. EVIDENCE: There was evidence from records seen, of regular monthly meetings with service users, to involve them in day to day decision making, ascertain their views on the service provided and to plan future events. From the care records seen, where there was an identified need an action plan or risk assessment had been completed. The records showed that regular reviews of risk assessment had been carried out. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 10 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 standard(s) 12,14,15,17 Service users were supported to access a range of social, occupational and recreational activities that are located in the community and socially valued. Dietary needs of service users were known and understood and efforts were being made to provide a balanced and varied selection of food to ensure a good nutritional intake. EVIDENCE: A sample of care records demonstrated that service users were encouraged and supported to access a range of leisure and recreational activities in the local community. Records showed that participation in socially valued activities was also encouraged. Activities included, sports, college placement, day centres, social activities such as playing pool, visiting the local pub, meals out, attending football matches. Some service users had been supported to obtain unpaid employment. Records showed that service users were supported to maintain contact with relatives and friends, through a variety of methods, including telephone contact, supported visits and the provision of transport in some cases. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 11 It was reported that service users were being supported to have a holiday in the summer. Since the last inspection the manager reported that a full audit of the quality, variety and nutritional content of the meals provided had been undertaken. It was planned that all flats will be issued with shopping guidance, recipes and suggested menu plans to choose from and to be agreed with service users, but that offered nutritionally sound meals. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 12 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 standard(s) 18,19,20 The personal and healthcare needs of service users were adequately met. The home has made some progress with regard to the arrangements for administration of medication. There were continued shortfalls, in the training of staff and adherence to policies and procedures, EVIDENCE: Assessments identified specific health needs of service users, risk assessments and health action plans were in place where a health issue had been identified. From a sample of care records it was evident that service users were supported to access community based health services ie G.P, dental and ophthalmic services and they received regular health checks. A relative, regarding the foot care of one service user, had raised an issue. This matter was discussed with the senior staff involved. A recommendation was made for a referral to chiropody services for assessment and guidance. The medication records in two flats were inspected, the evidence in both flats was of generally good record keeping. In flat 3 it was noted that there were two signature omissions from the sample of records seen, all other records were appropriately maintained. The senior in charge gave a satisfactory account of the procedure for addressing these matters. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 13 Since the last inspection, two incidents with medication have occurred which have been managed by the service. A report of the outcome and conclusion of the service investigation must be forwarded to the CSCI. It was reported by the acting care manager that a review of the medication policies and procedures was being undertaken as a result of one incident. Some progress was reported relating to a previous requirement to provide staff with certificated training in the management and administration of medication, 5 more staff had enrolled on a distance learning training programme, 3 staff had undertaken the training. It was recognised by the manager that further training was required and assessments of competence must also be carried out and reviewed regularly. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 14 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 standard(s) 22. The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. EVIDENCE: The service has a complaints procedure that was available in the Statement of Purpose and in a more user friendly format, in the Service User Guide. A complaint had been received by the CSCI prior to this visit. The matters raised by the complainant were discussed with the manager and senior staff. A separate report has been produced in response to the complainants concerns. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 15 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 standard(s) 24,25,26,27,30. The standard of the environment within this home is good providing service users with a comfortable and homely place to live. EVIDENCE: Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 16 The service is divided in to three units, Cally House, Cauldon place and Canalside each have their own front entrance, and garden area. The accommodation is divided into flats of which 3 provide single accommodation, the others provide from 2 to 6 beds each. Each unit has it’s own, lounge, kitchen and eating area, bathing and toilet facilities and staff team. This inspection included observation of flat 3 and 4 Cauldon Place and flat 4 Canalside. All areas had comfortable communal space provided and since the last inspection a total refurbishment of one flat had been undertaken. In this area the standard of furnishing and décor was very high. A service user confirmed that both of the occupants had been involved in the selection and purchase of furniture, fittings and accessories. A small sample of bedrooms showed that service users were able to personalise their rooms and were encouraged to take responsibility for them. Each service user was reported to have a key card to access their own flat and front door, if risk assessment indicated that it was appropriate for them to have one. Bedroom door keys have also been provided for service users. A domestic style of furnishings and fittings was noted throughout the home. Matters outstanding from the previous inspection included a recommendation to recover the dining room chairs in flat 2. The laundry facilities were not inspected during this visit. The home appeared to be clean and was free from offensive odours, from the observations of the inspector. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36. Staff morale was good resulting in a workforce that works positively with service users to improve their quality of life. After a period of considerable instability in staffing there is now a more stable staff team offering consistency of care within the home. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: The staff rota’s showed that 12 staff were deployed during the morning shift, and 10 for the early evening shift. Night staffing levels were for 4 waking staff. It was noted from the rota’s and from discussion that on occasions the night staffing levels were reduced to 3. The service must ensure that a risk assessment is in place for these occasions, any emergency procedures are amended and agreed with the relevant authorities, to reflect the reduction in numbers and that all staff are made aware of the changes and their responsibilities. This inspection included discussion with two staff and the manager, one had been a senior for some time, the second had recently been promoted. Both Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 18 demonstrated a sound knowledge of the needs of the service users in their care. Since the last inspection it was reported that staff had received training in Autism, Person Centred Planning, care planning and Crisis prevention training, which included, diversion techniques for the management of challenging behaviour. A staff recruitment drive had resulted in 10 new staff being employed at the home, reducing the numbers of agency staff required. All new staff who had little or no previous care experience were reported to have been enrolled on TOPSS induction programmes. Staff supervision was reported to be undertaken regularly, records were not checked at this inspection. A requirement of this and the previous inspection was to ensure that all staff responsible for the supervision of others receive training to enable them to undertake this role effectively and confidently. Since the last inspection it was reported that 7 staff have been nominated for NVQ level 2 training. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,42 The management arrangements at the home were adequate. Some shortfalls were identified for action by the providers and the manager. EVIDENCE: The manager had applied to be approved as the care manager for the home, the application was being processed by the CSCI. A requirement of the last inspection regarding Quality Monitoring and Assurance, had not been addressed within the time scale indicated. The manager reported that the service had recruited some one to undertake the audits and monitoring from June 2005. Regulation 26 visits must be carried out monthly and copies of the reports retained in the home and copied to the CSCI. Records of fire drills and training indicated that drills for both day and night staff had been undertaken in January 2005. It was established at the time of Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 20 this inspection if all staff had received a fire drill. Guidance from fire safety officers states that all staff must receive at least two fire drills per year. Additional fire training should also be provided. Records showed that fire alarms were tested weekly, a fire risk assessment had been updated in January 2005, emergency lighting tests were undertaken monthly and fire extinguishers were serviced and checked in February 2005. Risk Assessments were in place. At the previous inspection the hot water temperatures in the kitchens of the flats was not adequate, this matter was discussed. The evidence of this visit, was of a rise in temperature, the service must confirm to the CSCI that it now complies with the EHO and Health and Safety guidance in this respect. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 4 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 x x 3 Standard No 11 12 13 14 15 16 17 x x 1 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cauldon Place Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 22 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 20 Regulation 13 Requirement Ensure all staff responsible for the safe administration of medication have completed a certificated course.(Previous timescale 20 April 05 not met) Ensure that medication is signed for at the time of administration. (Previous timescale not met) 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) The Registered Person must ensure that staff who have the responsibility for supervision have been trained to do so. All staff must be involved in two fire drills per year and receive additional fire training. A report of the outcome and conclusion of the service investigation into the two incidents involving medication must be forwarded to the CSCI. The service must ensure that a risk assessment is in place for when night staff levels are reduced from 4 to 3, and any emergency procedures are amended and agreed with the v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Timescale for action 04 July 2005 2. 3. 20 39 13 26 04 May 2005 04 June 2005 4. 36 18 04 August 2005 31 December 2005 04 May 2005 5. 6. 42 20 13 13 7. 34 13 04 June 2005 Cauldon Place Version 1.30 Page 23 relevant authorities 8. 42 13 The Registered Provider must confirm to the CSCI that it now complies with the EHO and Health and Safety guidance in respect of hot water temperatures. 04 June 2005 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 19 Good Practice Recommendations Refer service users to Chiropody services as necessary for advice on foot and nail care. Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Stafford - 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 Cauldon Place v227237 e51-e09 s8207 cauldon place v227237 040505 stage 4.doc Version 1.30 Page 25 - 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. 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