Inspection on 10/05/05 for Caldicott House

This inspection was carried out on 10th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Caldicott House 10/05/06

Caldicott House 19/11/05

Caldicott House 24/03/05

Caldicott House 14/06/04

Caldicott House 05/12/03

Caldicott House 08/10/02

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Caldicott House 27 Old Bath Road Leckhampton Cheltenham Glos, GL53 7QE Lead Inspector Simon Massey Announced 10 May 2005 10:00 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 House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Caldicott House Address 27 Old Bath Road Leckhampton Cheltenham Glos GL53 7QE 01242 221343 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) H5M030Wright@mencap.org.uk Royal Mencap Society Mrs Suzanne Harris Care Home - personal care 6 Category(ies) of Learning Disability (6) registration, with number of places Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24 March 2005 Brief Description of the Service: Caldicott House is a semi-detached house in Cheltenham. It is a residential home for six adults with learning disabilities. It is very close to the town centre and is within walking distance for the residents. There is a short front lawn and pathway leading to the front door. At the rear of the property there is a large lawned area and patio. The home has three stories. On the ground floor there is a larger entrance hall, lounge and kitchen. There is also one bedroom on this level. On the first floor there are five bedrooms, a staff room and two bathrooms.The second floor is used for storage and is not part of the registration. The home is staffed and run by the Royal Mencap Society. The house is owned by the local Mencap group and the property is maintained by the New Era Housing Association. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during the day on May 10th 2005. The inspector met with the acting manager and also interviewed two members of the care staff team. Five of the six people who live at the home were spoken to and contributed important information to the inspection process. Comment cards were left at the home for staff not on duty and also for relatives or friends. Records were examined and also an inspection of the environment. What the service does well: What has improved since the last inspection? The home has continued to improve its administration processes and also the daily recording in the individual personal files. The garden has been kept and maintained more consistently which has helped service users to make the most of this private area. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 6 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. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.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 Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.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&5 The home has a Statement of Purpose and Service User Guide that complies with the regulations and reflects the service provided. EVIDENCE: Following the previous inspection the home has now updated the Statement of Purpose and Service User Guide to ensure that all the information is up to date. All service users have contracts in their files and also tenancy agreements. There have been no admissions to the home during the past twelve months. The acting manager confirmed that the work had been completed on the Statement of Purpose and Service User Guide. Copies are being sent to the Commission. The changes relate to factual information that needed to be updated rather than changes in the operational policy or the philosophy of care. A sample of three service user files were examined. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.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) 6,7,8,9&10 The home produces good outcomes for all these standards, having a care planning system in place that is effective in accessing needs and developing realistic goals and targets. EVIDENCE: Plans are reviewed on a regular basis with the full involvement of the service users. The care plans reflect the individual needs and preferences of the service users, and contain details of any limitations that are considered in their best interests. The home has risk assessments in place that cover a range of activities and issues, both in the home and in the community. The inspector examined four personal files and spoke to service users about their involvement and understanding of the care planning system. The care plans are clearly written, with detailed recording, and risk assessments are all dated and reviewed. Service users spoken to were all very positive about the input they receive from their key-workers, and evidence was seen throughout the visit of positive and respectful relationships between staff and service users. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.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) 11,12,13,14,15 &16 The home supports people to have individualised lifestyles, both in terms of daily activities and also leisure time. People are supported to develop skills that will maintain or increase independence. EVIDENCE: Service users maintain regular contact with families, with regular visits to the home, meetings in town and also trips to stay with families if this is wanted. The individual rooms all reflect people’s personal interests and there are also organised trips to concerts, pubs, the cinema and annual holidays. Service users have a responsibility for, and an involvement in, all the domestic chores undertaken within the house. Examination of records and interviews with staff and service users demonstrated the range of activities being supported. All service users expressed satisfaction with their current routines and could not identify any unmet needs in these areas. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 11 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 home has systems in place for monitoring health needs that are effective and meet the needs of the service users. The home provides a high standard of personal care and support. EVIDENCE: The home monitors individual health needs and records all appointments that occur. There has been involvement from outside professionals relating to health issues, including dementia, behavioural concerns, diets and mobility issues. The home has provided training for some staff in the area of dementia and this has been cascaded down to the staff team. Staff have an awareness of peoples individual issues and the action or support being provided by the home. The medication storage and administration was being carried out professionally and an example of good practice was seen in the medication folder. This provides extra information to staff about the side effects, the different names and the purposes of individual medication. The individual files contained details of correspondence with outside professionals and the records showed the action being taken by staff in response to this input. The individual diaries and personal files showed clear recording of concerns being monitored and appropiate action being taken. The homes medication storage and administration system was examined and seen to be in order. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 12 Records were seen of medication training that has been completed by staff. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 13 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 &23 The home provides a safe environment for service users in which they are respected and treated with dignity. EVIDENCE: Through observation and interview it is evident that service users are able to express their concerns and feel confident about approaching staff. There is also a complaints process in place that meets the required standard. Staff are provided with training in the area of adult protection during their induction and foundation training. Service users commented upon the attitude of staff, with two people saying that, “they always listen when I have something to say” and also saying that when they “talk to the staff they know something will be done about it”. All service users were very positive about the staff team and the care and support they receive. Staff interviewed stated that they had no concerns about the health and safety of service users in this area and that the training provided had been appropiate. No complaints have been made in the home or to the Commission. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 14 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) 24,25,26,27,28&30 The environment of the home is maintained to a good standard, being clean and homely throughout. EVIDENCE: Service users are fully involved and consulted about decoration and alterations to the building. The home has ample communal space allowing privacy and also a well maintained garden that is well used by the service users. Four bedrooms were seen during this visit and all were personalised and well furnished and maintained. The exterior paintwork that was recently repaired has started to deteriorate at the front of the house and requires attention With the exception of two bedrooms the entire environment was inspected during this visit. The only item requiring attention identified during this visit was the exterior paintwork at the front of the house. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 15 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) 31,33,35&36 The home has a core of established staff who at this and previous inspections have demonstrated an excellent understanding of the needs of the service users and of the aims and objectives of the home. EVIDENCE: Staff interviews and recording show that the staff work as a team, with good communication systems in place and good support available both from within the team and from the management. 1 staff member is currently undertaking NVQ training but there are plans for others to start soon. The manager and deputy are also undertaking NVQ training. Due to management changes and occasional staff shortages in the past the NVQ training has taken awhile to build up momentum but this is now being addressed. Staffing records, staff meeting minutes and training records were examined. Evidnce was also obtained from interviews with staff, the acting manager and the service users. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 16 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 home is being run and managed in a professional and competent manner and is meeting the needs of the service users. EVIDENCE: The registered manager is currently seconded temporarily to another Mencap establishment and the home is being run by the deputy manager in the interim period. The Commission were consulted and informed about this development. The deputy has several years experience of working in the home and is able to demonstrate a good understanding of the needs of the service users and of the range of responsibilities they are undertaking. They are also undertaking NVQ4 training. The acting manager receives support one day a week from the registered manager, and also receives monthly visits from the area manager, who has the responsibility for completing the required Regulation 26 visits All recording and administration examined was up to date as were all the records of health and safety checks. These include fire safety testing, water temperatures, routine environment checks, electrical tests and the gas central heating system. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 17 Staff supervisions are booked and the acting manager stated that they planned to complete these every two months. Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 18 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 3 Standard No 22 23 ENVIRONMENT Score 4 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 x 4 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Caldicott House Score 4 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 3 x D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 19 no 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. 2. Standard 24 32 Regulation 23(2)(b) 18(c)(i) Requirement Timescale for action 31/10/05 Repairs must be made to the external paintwork at the front of the house The home must ensure that a 31/12/05 minimum of 50 staff undertake NVQ training by the end of 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 Good Practice Recommendations Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 20 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Caldicott House D51_D03_S16394_Calidcott House_V222835_100505_Stage4_A.doc Version 1.30 Page 21 - 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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