Inspection on 26/08/05 for Caldicott

This inspection was carried out on 26th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Caldicott 09/08/07

Caldicott 16/03/07

Caldicott 03/01/06

Caldicott 17/01/05

Caldicott 02/08/04

Caldicott 10/02/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Caldicott 4 Caldicott Avenue Bromborough Wirral CH62 6DJ Lead Inspector Beate Roth Unannounced Friday, 26 August 2005 th 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. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Caldicott Address 4 Caldicott Avenue, Bromborough, Wirral, CH62 6DJ 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) 0151 334 2122 Alternative Futures Limited Alan Meadows PC Care home only 3 Category(ies) of LD Learning Disability - 3 registration, with number of places Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only adults (aged 18 -64 yrs) with a learning disability may be accommodated. 2. Mr Alan Meadows to complete an NVQ Level 4 qualification in management by 2005 and demonstrate that his existing qualifications are the equivalent of an NVQ Level 4 in Care. Date of last inspection 17/01/05 Brief Description of the Service: 4 Caldicott Avenue is registered to provide personal care for 3 service users with a learning disability. The home is operated by Alternative Futures Limited, a registered charity operating in the North West. The premises are owned by Alternative Housing Association. 4 Caldicott Avenue is a detached dormer bungalow, situated in a quiet residential road, within walking distance from a small parade of local shops. There are two single bedrooms on the ground floor and one single bedroom on the first floor. Communal areas of the premises comprise a large lounge, with a soft area at one end, and a separate dining room. There is a domestic style kitchen, off which is a separate laundry area and an office. There is a walk in shower room/wc situated on the ground floor. On the first floor there is a further bathroom /WC with a whirlpool bath. There is a chair lift to the first floor. To the rear of the home is a garden to which there is level access. There is car parking at the front of the home. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during an afternoon. During the inspection time was spent in the office examining records and policies and procedures and talking to the manager. A tour of the home was undertaken. Staff were observed delivering care to service users. Staff were spoken with. What the service does well: What has improved since the last inspection? What they could do better: The contracts/statement of terms and conditions need to include the cost of the service and the way they are drawn up could better support the interests of service users. An improvement needs to be made to the risk assessments around the use of bedrails at the home. Medication must be safely stored at all times. Attention is needed to the decoration in the dining room. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 6 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. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 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 Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 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) 3 and 5 The assessed needs of service users are met. The contracts/statement of terms and conditions could better support the interests of service users. EVIDENCE: No new service users have come to live at the home since the last inspection. Records show that the assessed needs of service users are met by close liaison with appropriate health and social care agencies. Comprehensive induction and foundation training is provided to staff. Staff are then encouraged to undertake an NVQ 2 in Care which includes training around caring for people with a learning disability. At present four staff have obtained relevant social care qualifications. The remaining staff are currently working towards this. There is written information available providing individual guidelines for communication with service users. This information is being further developed. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 9 Tenancy agreements with Alternative Housing and support agreements with Alternative Futures are in place. The support agreements (contracts/terms and conditions) cover most of the information detailed in this standard. Information around the actual cost payable was not available. This is to be addressed. The support agreements have been signed by the manager for the home. The manager reported that as the service users would not be able to understand the content of the support agreements, attempts have been made to approach an advocate and an advocacy service has been recently identified. In accordance with the National Minimum Standards it is recommended that service users be supported by family, friends and/or advocate as appropriate when drawing up the support agreement. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 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 standard(s) 6 and 9 The care plans reflect the assessed and changing needs of service users. Some risk assessments need to be revised to better promote their well being. EVIDENCE: The lifestyle plans for service users include, risk assessments and details of support needed to enable service users to undertake activities within and outside the home. Daily records are made in each service user’s file. Key workers are allocated to each service user. There was evidence of reviews having taken place of lifestyle plans. Reviews are due and new documentation that has been introduced will ensure that each aspect of the service user plan as detailed in standard 2 of the National Minimum Standards, is covered. Behaviour management plans around managing the behaviour of service users who can display challenging behaviour are available. Risk assessments are carried out for both personal and environmental risks. Risk assessments around the use of bed rails are available. These assessments are being reviewed on a 6 monthly basis. The risk assessments must indicate that the timescale for review is in accordance with the needs of the service user and the assessed risk. The risk assessments for the use of Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 11 bed rails did not indicate who is to provide the instruction to new staff around the use of the bed rails, any changes to a service users needs that may effect the use of the bed rail and whether the service user continues to need the bed rails. There are NHS guidelines on risk assessing bed rails available at the home. It is suggested that these are used in order to produce a comprehensive risk assessment. Since the last inspection there has been a change to the bed rails used for one service user and the risk assessment has not been updated. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 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 standard(s) 11, 12, 13 and 16 Service users are provided with opportunities for personal development and appropriate activities that ensure they are part of the local community. The rights of service users and their independence is recognised in their daily lives. EVIDENCE: The records and observations indicated that service users are encouraged to develop independent life skills such as preparing food and making choices. None of the service users at 4 Caldicott Avenue attend day or training centres or go to employment projects. Programmes of suitable activities and holidays are in place to suit their choices and abilities. Records showed and staff spoken with said that the service users make use of community facilities such as local pubs, shops and public transport. The home is located close to shops and other community resources. The home has its own transport, which enables community participation. Service users make use of specialist swimming and riding facilities where this has been assessed as appropriate. Observation showed that staff respect the privacy of the service users and promote their dignity. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 13 Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 14 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) 19 and 20 The health needs of service users are well met and in general they are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Visits to service users from medical/health care professionals take place in private. Records indicate that service users have access to medical/health care professionals as needed. Service users are helped to access healthcare services. Procedures for managing specific health needs are available. Since the last inspection the records around recording the health care needs of service users have been revised to ensure that this information is more comprehensive and accessible. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 15 The home has a medication policy and procedure in place. Staff who administer medication have all received training around the safe handling of medication. The home receives advice and guidance from the local pharmacy as necessary. Medication is in general stored securely, at the time of the inspection a liquid medication was on top of two of the medication cabinets. This was addressed at the time of the inspection. The medication administration records and corresponding medication were inspected and found to be accurately maintained. Since the last inspection, further information is available around recognising each type of medication as the medications are not individually stored and labelled. At the last inspection it was recommended that where service users are not able to consent, the decision to provide medication to a service user should be clearly documented in the care plans. At this inspection advice has been obtained from each service users GP. This information should also be documented in the care plans. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 16 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 systems in place for managing complaints ensure that service users views are heard and appropriate action taken. EVIDENCE: There is a complaint procedure that is more suited to the needs of service users with a learning disability. Staff reported that they elicit the views of service users in accordance with their abilities. Information is available to enable a complaint to be made on behalf of a service user by an advocate. The complaint procedure describes the stages of the complaint and the timescales for investigating complaints. The staff were aware of the content of the complaint procedure and how to respond to complaints. CSCI has not received any complaints about this service. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 17 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 and 30 The home is clean and generally well presented and provides a comfortable and pleasant environment for service users. EVIDENCE: In general the home is well maintained. The dining room requires attention. There is a hole in the wall and marks to the paintwork where a hole has been filled in. Steps have been taken to ensure the safety of service users at the home. Hot water temperature regulators have been fitted to the bath and shower. Records show that regular tests of the water temperature are undertaken. All radiators seen had low temperature surfaces, apart from the one in the office, to which service users do not usually have unaccompanied access. The first floor windows open so as not to pose a risk to service users. A sample of safety/maintenance check certificates and records were examined and found to be in order. The fire record books indicated that the fire drills and checks on the emergency lighting and fire alarms are occurring at the recommended frequencies. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 18 A tour of the home showed that the home was clean. It is clear the staff are working hard to ensure good standards of cleanliness are maintained. There are procedures for staff to refer to about hygiene and infection control. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 19 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) 33 and 36 Service users are supported and protected by the numbers of staff available and the arrangements in place for staff supervision. EVIDENCE: The staffing rota and discussions with the manager and staff indicated that there are enough staff available to meet the needs of the service users. Staff are deployed in accordance with their skills and abilities. There are currently no staff vacancies. Bank staff and the current staff team cover any staffing shortfalls. The same bank staff are employed in order to ensure consistency for service users. Records and a discussion with staff showed a team meeting had been held recently. A discussion with staff and records showed that staff receive supervision in accordance with the recommended timescales. Staff also have an annual appraisal. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 20 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) 38, 39 and 42 The management approach, quality assurance and the health and safety systems in operation at the home promote the wellbeing of service users. EVIDENCE: Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 21 A member of staff interviewed reported that they consider their views regarding the running of the home are sought and listened to. The views of service users are ascertained in accordance with their abilities. A complaint procedure is available. An equal opportunities policy is available. There are a number of quality assurance systems in place. Regular supervision and staff meetings are held. A member of staff reported that there is good communication between staff and management at the home and that the manager consults them regarding their views. The manager undertakes regular checks of the safety and presentation of the home. The service manager undertakes Regulation 26 visits. Audits take place of medication and finances. Dates of policies show that policies and procedures are regularly reviewed and up-dated to meet the requirements of legislation and the needs of service users. Training around safe working practices is made available to staff as part of their induction. There is a rolling programme of training opportunities provided and refresher courses are undertaken when needed. There are policies and procedures and risk assessments available that promote safe working practices. A sample of safety/maintenance check certificates and records were examined and found to be in order. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 22 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 x x 3 x 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x x 3 x Standard No 31 32 33 34 35 36 Score x x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Caldicott Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x x 3 x F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 23 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 5 Regulation 5, 17 Requirement Timescale for action 26/11/05 2. 9 13 3. 4. 20 24 13 23 The service users contracts/statement of terms and conditions must include the information detailed in Standard 5 of the National Minimum Standards for Care Homes for Younger Adults (previous timescale not met). A comprehensive risk 26/09/05 assessment must be available for the use of all bed rails. A review of the risk assessments for the use of bed rails must take place in accordance with the needs of the service user and the assessed risk. All medication must be stored 26/08/05 securely. The decoration in the dining 26/11/05 room requires attention (previous timescale not met). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Caldicott Refer to Standard Good Practice Recommendations F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 24 1. 2. 5 9 It is recommended that service users be supported by family, friends and/or advocate, as appropriate when drawing up the contract. It is recommended that the NHS guidelines on risk assessing bed rails that are available at the home be used in order to produce a comprehensive risk assessment. Caldicott F52 F02 S18973 Caldicott V246887 260805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Liverpool Area Office 3rd Floor, 10 Duke Street Liverpool L1 5AS 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. 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