CARE HOME ADULTS 18-65
4 - 6 Cavendish Road Felixstowe Suffolk IP11 2AX Lead Inspector
Julie Small Unannounced Inspection 11th October 2005 11:55 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 4 - 6 Cavendish Road Address Felixstowe Suffolk IP11 2AX 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) 01992 622000 Together: Working for Wellbeing Post Vacant Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (13) 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users must be under 65 years of age at the time of admittance to the home. 10th March 2005 Date of last inspection Brief Description of the Service: The home is situated in a residential area of Felixstowe within easy reach of the beach and local amenities, such as shops. The home is in two linked adapted domestic houses, providing accommodation on three floors. Cavendish Road has a small back garden, which is accessible to service users and is attractively designed. The home is registered for thirteen service users with mental disorder. Service users are aged below 65 years of age at the time of admission, but may remain at the home over 65 years of age, so long as the home is still able to meet the service user’s physical and mental health needs. The home is owned by Together, which was previously known as MACA. The homes manager is Janet Gentry. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place on Tuesday 11th October 2005 at the times 11.55 to 18.25. Regulatory inspector Julie Small undertook the inspection. The homes recently appointed manager Janet Gentry and deputy manager Lisa Miles assisted with the inspection. A tour of the building was undertaken during the inspection; only one occupied bedroom was viewed. Three service user records, two staff records, two staff personal development, the statement of purpose, service users guide, complaints procedure and staff meeting minutes were viewed. Eight service users were met, three service users were spoken to and two staff members were spoken to during the inspection, observation of work practice was also undertaken during the inspection. All records requested were provided promptly, the homes newly appointed manager was very receptive to the inspection process, and committed to improving the service provided. There are currently ten service users living at Cavendish Road, the manager informed the inspector that they are actively seeking to accommodate a further three service users and have received interest in these place, two pre admission visits are planned for the near future. What the service does well: What has improved since the last inspection?
Cavendish Road has had a manager in post for eight weeks. This was a requirement from the last inspection. The service users guide now contains information about service users views and how they are gained, analysed and used to improve services, this was a requirement from the last inspection. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 6 Three service users records viewed evidence that the homes ability to meet the needs of a person to the home is assessed prior to admission. This was a requirement from the last inspection. The manager, deputy manager and five staff have received the County Council POVA training. The deputy manager confirmed that protection of vulnerable adults (POVA) is included in the TOPSS (now Skills for Care) induction and foundation training programmes, which all newly appointed staff attend. This was a repeat requirement from the last inspection. The staff group have attended fire safety training; this was a requirement of the last inspection. All staff have received risk assessment training and are completing exercises regarding the completion of risk assessments in team meetings. The manager stated that tenders have been received for the further redecoration of the home. This was a repeat requirement from the last inspection. There was evidence that recent decoration had been undertaken. Damage from a recent flood to one bedroom has been repaired and redecorated, this room is now vacant, and this was a requirement from the last inspection. A damaged toilet has been replaced; this was a requirement from the last inspection. There were no offensive odours detected during this inspection, this was a requirement from the last inspection. The deputy manager stated that the problem with an offensive odour had been investigated and improved. The manager advised that regulation 26 reports are undertaken and forwarded to CSCI; these reports have been forwarded to CSCI. This was a requirement from the last inspection. Service user surveys have been undertaken and have been analysed by the homes head office. These are due to be presented to the service users of the home in the annual review, which will take place in one week. Evidence for this will be available for the next inspection; this was a requirement from the last inspection. The manager stated that the homes head office updates policies, though there is evidence that the home has recently designed a policy regarding personal car use for staff. Staff meeting records show that staff discuss updated procedures on a weekly basis. Policies were not viewed at this inspection, but evidence regarding the staff meetings show that staff are regularly updated on policies and updated policies. This was a requirement from the last inspection. What they could do better:
Service user plans must be regularly reviewed; this was a requirement from the last inspection. Full dates of recordings in service users records are not available at all times. The complaints procedure and ‘residents licence agreement’ found in service user records should be updated to show contact information for CSCI, both records refer to NCSC (National Care Standards Commission), which is out of date information.
4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 7 Three service user records viewed, one provided a risk assessment related to excessive hot water was present; two service user records did not. This was a repeat requirement from the last inspection and will be repeated in this inspection report. The home should produce a strategy to achieve 50 of care staff to have achieved at least NVQ level 2 by 2005. This was a requirement from the last inspection and will remain as a requirement. The deputy manager stated that service users are offered various activities within the local community, but some service users do not wish to participate. Three service users spoken to said that they do not have the opportunity to participate in activities and within the community. A recommendation that the home keep a record of when service users wish to, or decline to participate in proposed activities. One service user informed the inspector of a recent theft from their bedroom, the police have been informed. The home did not forward a regulation 37 notification to CSCI regarding this incident, and staff spoken to could not locate records of this event, copies of these records have since been forwarded to CSCI. 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. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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 Prospective service users can expect to be provided with the information they need to make an informed choice about where to live and their individual aspirations and needs are assessed. Service users can be assured that they will be provided with an opportunity to visit and to ‘test drive’ the home. EVIDENCE: The homes statement of purpose and service users guide were viewed these were up to date, in good order and well maintained. Both the statement of purpose and the service users guide provide clear information that service users and their representatives may need in making decisions about where to live. The previous inspection report included a requirement where service users views should be included in the service users guide. Though this had not been completed prior to the inspection, the manager inserted records of service users views about the service they receive, from a recent survey. Three service user records viewed contained Care Management and Care Programme Approach (CPA) assessments. The records included care plans, which were generated from these assessments. The records evidence that service users aspirations and needs are assessed prior to moving into the home. The manager stated that they feel further information is required from assessments and is planning to undertake the task of seeking more comprehensive assessments, from other professionals completing them. The manager advised that this was discussed in a recent team meeting. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 10 The manager is currently seeking to accommodate a further three service users to the home. The manager stated that three referrals have been received by the home, and plans have been made for the prospective service users to visit the home. Two service users spoken to confirmed that prior to moving into the home they had been invited to the home to look around. One service user said that they had visited the home to look around and had a tea visit, before they decided that they would move in. One service user said that they visited the home with their social worker. One service users records viewed showed that the service user had been accommodated to the home on a one month trial period; this was documented in the records. Three service user records viewed included residents licence agreements, these should be updated because they refer to NCSC on the second page, and residents licence agreements should be updated to the current CSCI. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8, 10 Service users can expect that they are consulted on and participate in, all aspects of life in the home and that information about them is handled appropriately. Service users assessed and changing needs should be reflected in their individual plan. EVIDENCE: Two service users spoken to said that they attend a meeting every Sunday. The service users said that they talk about the home, and they can discuss anything they are not happy with, would like to change about the home or any other issues they wish to discuss with regards to their life in the home. Three service user records show that service users and their key workers discuss the homes policies and procedures and their contents on a regular basis. The manager stated that service users have recently completed ‘service user surveys’, documentary evidence was viewed. The surveys have been analysed by the homes head office and will be presented to service users in an annual review, which is due to take place one week following the inspection.
4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 12 Three service users records were viewed; these provide an individual plan of care, which is generated from the CPA (Care Programme Approach) assessment. The service users care plan includes service users day to day needs. There is no evidence that care plans are regularly reviewed with service users changing needs and goals, this should be regular practice for care workers. Several entries in daily progress records in two service user files, do not provide the full date, the day and month is recorded but not the year of the entry. One service user file contained a care plan action sheet, this provided entries recorded by a care worker with day and month but no year. This evidence is not valid, as the recordings may have occurred at any year in the service users life. All recordings regarding the care provided to service users should be dated and signed by the author of the record. Service user and staff records are stored in a secure place in the home. Three service user records viewed provided a ‘shared information sheet’, which explains what will happen with any information regarding the service user during their stay at Cavendish Road, this is signed as agreed by the service user. One service user was spoken to and talked about a recent theft of medication, jewellery and a mobile telephone from their bedroom. The police had been called, no regulation 37 notification has been forwarded to CSCI and staff could not locate any record regarding this incident in the service users records. All records of significant events should be accessible in the home, and CSCI should be informed of any significant events. These records and regulation 37 notification have since been forwarded to CSCI. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 16 Service users should be encouraged to be part of the local community. Service users can expect that their rights are respected and responsibilities recognised in their daily lives. EVIDENCE: The deputy manager stated that service users are regularly offered various activities within the local community, though some service users choose not to participate. The deputy manager provided evidence of this through service user meetings minutes. One service user spoken to said that they often go shopping in the Felixstowe area, travel by train into the Ipswich area and occasionally go out for pub meals at the pub situated across the road from the home. One service user said that they do not go out often, and stated ‘I would like to get out more but I wouldn’t know where to go around here’. The service user said that they have been for lunch in the pub across the road from the home and go out with a family member for a coffee. One service user spoken to said that they don’t get out and about much, they said they go to the shop.
4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 14 During the inspection staff were observed working with a service user, they were planning to go shopping. Staff and the service user had planned to use the home’s car to attend the shops, but decided to walk to local shops and catch a taxi to return to the home. The shopping trip was undertaken. It was suggested that staff record occasions where service users have declined or accepted to participate in proposed activities in the local community, and to advise service users of available resources in the local community. During a tour of the building, service users were asked permission to enter their bedroom. A service user who was in their room at the time granted this. Staff spoken to said that all service users are provided with a key to their bedroom door, which also unlocks the front door. One service user who was spoken to confirmed this. One service user spoken to said that they could use all the shared areas in the house, such as the lounge, dining room and gardens, when they like. Two service users spoken to said that they have family members visit them at Cavendish Road. One service user spoken to said that service users take it turns to help prepare for, cook and clear up after meals. Service users also help with shopping for the meals. One service user spoken to said that they shop and cook for themselves. There is a smoking room in the home that service users can use if they wish and service users can also smoke in the garden area if they wish. Staff at the home discourage smoking in other shared areas of the home. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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): 20 Service users can expect to retain, administer and control their own medication where appropriate, and be protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: During the inspection, staff was observed assisting two service users to take their medication. Medication is stored in an appropriate manner, when assisting the service user, medication was removed from the blister pack and placed in a small plastic cup and handed to the service user. Staff signed records following the assistance. One service user spoken to said that the staff keep their medication as they sometimes forget to take it, and are happy for staff to assist them. One service spoken to said that they administer their own medication, which they keep in a locked drawer in their room. The service users records were viewed their medication arrangement were recorded, and include a risk assessment regarding the self-medicating arrangement. One service users records were viewed, there was evidence that the service user had self medicated, but had not taken their medication. The medication arrangements record was up dated to show that the service user is now assisted with their medication.
4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 16 Two staff personal development folders evidence that staff have attended training on ‘Boots’ monitored dosage system and medication procedures. One service user was spoken to informed the inspector that they had had a theft from their bedroom of their medication and other items, such as jewellery and a mobile telephone. The police, pharmacy and doctor were informed. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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 Service users can expect that their views are listened to and acted on. Service users can expect that they are protected from abuse, neglect and self-harm, but Cavendish Road has shortfalls with regards to the security of the building. EVIDENCE: Cavendish Road complaints log was viewed; this shows several complaints regarding the same incident over the last twelve months. The complaint was involved one service user complaining about noises coming from a peers room, details of the complaint, action taken and the service users views regarding the resolution was recorded. The manager confirmed that a resolution has been sought and all parties involved are satisfied. The complaints procedure was viewed; this explains service users rights to complain at any time. The complaints procedure should be updated to show contact details of CSCI, the current complaints procedure provides out of date information and refers to NCSC. Two service users spoken to confirmed that they knew what action to take if they wished to make a complaint regarding the home. But service users spoken to discussed issues of feelings of helplessness within their life, and that what they are provided with they should be happy with. One service user said ‘anywhere is better than hospital’. Service users may be reluctant to complain about the service they receive, fear of being returned to hospital and being seen as a problem to the home was stated. One service user said that they had been burgled when living at Cavendish Road. The service user said that medication; jewellery was stolen from their
4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 18 room. The service user confirmed that they were happy with the action of staff at the home; staff had assisted with calling the police, informing the doctor and the pharmacy. One member of staff was spoken to about the burglary, they confirmed that this had happened recently, but were unable to locate any recordings about the incident, and stated that they were unaware that they should report incidents to CSCI. These records have since been forwarded to CSCI. The staff member spoken to said that the bedroom lock had been repaired. The security of the building was discussed because the police had not investigated the incident; there is no evidence with regards to who undertook the burglary. No further action has been taken to improve the security of the home, and the staff member spoken to confirmed that service users do leave the home and put the door ‘on the latch’. The security of the building should be examined, providing a safe environment for service users to live in. Training records viewed show that the manager, deputy manager and a further five staff have attended POVA training. The deputy manager confirmed that protection of vulnerable adults is covered in TOPSS (now Skills for Care) induction and foundation training, which all new staff attend. Staff also receive an in-house induction where they are informed of details regarding policies and procedures of the home, including dealing with aggression from service users and reporting concerns of abuse. Two staff records viewed show that the staff had received criminal records bureau (CRB) and POVA checks prior to commencing in their work role. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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): 27, 28, 30 Service users can expect that the home is clean and hygienic and that shared spaces complement and supplement their individual rooms. Service users can be assured that toilets and bathrooms provide sufficient privacy and meet their individual needs. EVIDENCE: The home is clean and hygienic and is free from offensive odours. The home is undergoing a redecoration, approximately half of the property has been decorated and the manager confirmed that tenders have been received for work to be completed on the remainder of the home. Previous inspection report requirements regarding a bedroom which had been damaged from a flood and damage to a toilet be made good, have been actioned. The laundry room was viewed during a tour of the building this room was clean and tidy, providing a washing machine and a drying machine. The laundry room is away from areas where food is prepared and transported. During a tour of the building it was viewed that there are two toilets and bathrooms on each floor where bedrooms are situated. The ground floor provides toilet facilities accessible from communal areas. Each toilet and
4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 20 bathroom is provided with a hand washbasin, hand wash gel and disposable hand drying towels. Bathrooms are provided with showers or baths, and some provide both shower and bath, so providing service users with choice of bathing facilities. All toilets and bathrooms were viewed to be very clean. The staff at the home are provided with a ‘sleeping in’ room for when they are doing a sleeping in duty, the office provides space for storing personal belongings if required. Cavendish Road provides a well kept garden; the garden is mainly laid to shingle, with a decking area provided with seating. Service users can smoke out doors if they wish, or are provided with a comfortable sitting room to smoke in if they wish. The home provides a no smoking lounge, which is comfortable, there is currently a room being prepared to provide a quiet room on the first floor where service users can entertain guests or have meetings if they wish. The kitchen and dining room have been recently re equipped and decorated, both are attractive and sufficient for their use. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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, 35, 36 Service users can expect that an appropriately trained and well supported and supervised staff group meets their individual and joint needs. Staff at Cavendish Road do not currently meet targets for the competence and qualification of staff. EVIDENCE: Two staff records viewed provide copies of application forms, two written references, and CRB and POVA checks, which provide confirmation that staff working at the home provide requires qualities of individual staff. Job descriptions for all staff roles within the home were viewed, these clearly illustrate the responsibilities of each work role at Cavendish Road. Cavendish Road does not currently meet the target of 50 staff to have achieved at least NVQ level 2 by 2005. There is currently eight regular staff and four relief staff that work at Cavendish Road, one staff have achieved their NVQ level 3 award. Two staff have recently been registered to work towards their NVQ award and two staff are working on their NVQ award. The manager confirmed that there are plans for them to attend an assessor’s course and provide assessment for the unqualified staff at Cavendish Road; the deputy manager had also sought out possibilities of attending assessor training. Both the manager and the deputy manager do not hold a relevant care qualification so would not be able to provide assessment for the staff team, the awarding
4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 22 body state that assessors should have the care qualification or the equivalent of the level of award they assess. A plan for how Cavendish Road propose to meet the qualification target for 2005 should be forwarded to CSCI, this is a repeat requirement. Two staff personal development records were viewed, these provide a training plan for the individual staff member and certificates of training they have attended. Certificates for staff training are also displayed on the office wall. Since the last inspection the staff group have received fire safety, risk assessment training and several staff have attended POVA training. Personal development records show that receive regular training which is relevant to their work role, including TOPSS (now Skills for Care) induction and foundation, appointed person first aid, working with people who self injure, managing conflict situations, Boots monitored dosage system, working with violence and aggression, understanding epilepsy and drugs and alcohol. One staff member spoken to said that they receive supervision on a four weekly basis and attend staff meetings once a week. The staff member confirmed that they receive sufficient support and supervision; the staff member said that they had also received a three month and six month probation appraisal. Minutes from staff meetings were viewed; these included informing staff of the expectations of their role, discussions about issues at work and with service users and regular updates and discussions about the homes policies and procedures. Policies and procedures are updated by the home’s head office, the home has recently developed their own staff car use procedure, and this was discussed in a staff meeting. The deputy managers personal development records were viewed this showed that they have received training which includes, supervision skills, key working and care planning and recruitment and selection, which evidences that the management team receive training to inform their work role, and providing staff with effective supervision. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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 Service users can expect that they benefit from a well run home and that their views underpin all self monitoring, review and development by the home. EVIDENCE: The home has a newly appointed manager, in place for eight weeks. The manager confirmed that an application for registration has been forwarded to CSCI. The manager has achieved the RMA (Registered Manager Award), management level 3 and has achieved half of their level 4 care award, and is hoping to complete this award. The manager has sufficient knowledge and experience to undertake their duties effectively, the manager’s job description was viewed, and this clearly indicates roles and responsibilities. Regular regulation 26 records are forwarded to CSCI, undertaken by senior management of Cavendish Road. Regular service user surveys are undertaken regarding the service they receive, questionnaires were viewed. Service user surveys are analysed by head office, findings of a recent survey is due to be presented to service users the following week at the home’s annual review.
4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 24 Two service users spoken to said that they attend service user meetings every Sunday, where they can talk about issues in the home and the service they receive. One service user said that the minutes to the meetings are recorded and the service users are given a copy, and if staff need to action something from the meeting they are told what is happening. 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 X 3 Standard No 24 25 26 27 28 29 30
STAFFING Score X X X 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
4 - 6 Cavendish Road Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000048200.V257657.R01.S.doc Version 5.0 Page 26 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 YA6 Regulation 15 (2) Requirement The Registered Persons must ensure that the service users plans are regularly reviewed and current. This is a repeat requirement. The Registered Persons must ensure that risk assessments related to excessive hot water for each service user are reviewed and completed. This is a repeat requirement. The Registered Persons must provide the CSCI with a copy of the home’s training strategy to achieve 50 care staff with NVQ by 2005. This is a repeat requirement. The Registered Persons must ensure that the complaints procedure provide the name, address and telephone number of CSCI The Registered Person must give notice to the CSCI without delay of the occurrence of any theft, burglary or accident in the care home The Registered Persons must ensure (to promote and make proper provision for the health
DS0000048200.V257657.R01.S.doc Timescale for action 13/10/05 2. YA42 13 (4)(b)(c) 13/10/05 3. YA32 18 (c)(i) 13/10/05 4. YA22 22 (6)(b) 13/10/05 5. YA23 37 (1)(f) 13/10/05 6. YA23 12 (1)(a) 13/10/05 4 - 6 Cavendish Road Version 5.0 Page 27 and welfare of service users), that the building is secure and safe. 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. Refer to Standard YA13 YA6 Good Practice Recommendations It is recommended that records reflect where service users have accepted or declined any proposed activities within the community It is recommended that accurate dates be included in all records 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 4 - 6 Cavendish Road DS0000048200.V257657.R01.S.doc Version 5.0 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!
