Inspection on 10/05/06 for Caldicott House

This inspection was carried out on 10th May 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Caldicott House 19/11/05

Caldicott House 10/05/05

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 Mr Simon Massey Key Unannounced Inspection 10th&12th May 2006 10:00 Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Caldicott House Address 27 Old Bath Road Leckhampton Cheltenham Glos GL53 7QE 01242 221343 01242 257422 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) www.mencap.org.uk Royal Mencap Society Mrs Suzanne Harris Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th November 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 DS0000016394.V291557.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 10th and 12th May 2006. The inspector met with the acting manager, care staff and service users. Records relating to care planning, staff recruitment and training, Health and Safety, medication and maintenance were examined. An inspection of the environment was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that staff complete their NVQ training. The acting manager needs to go through the registration process. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 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 House DS0000016394.V291557.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 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 the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a Statement of Purpose that meets the required standard. The home has an admissions policy that complies with the regulations. EVIDENCE: The acting manager has updated the Statement of Purpose and Service User’s guide to ensure they include current and accurate information. The home has had no admissions for several years but there is an admissions procedure in place that meets the standard. This is a national policy and procedure provided by the Royal Mencap Society. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 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 the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Detailed care plans help ensure that needs are identified and action taken. More detail around goals and objectives would provide clearer guidance for staff in how goals are to be achieved. Risk assessing is used to promote independence and protect service users. EVIDENCE: All service users have care plans in place that have been regularly reviewed, with the involvement of the people concerned. These plans contain details covering all aspects of care and support. Records show input from outside professionals and additional assessments being carried out when necessary. It would be possible for the home to provide more detail in the identified goals and objectives, which are recorded as a result of the review meeting. These could specify what was to happen for goal to be achieved, the time scale and who has the responsibility for progressing the issue. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 10 Additional protocols have been written for the management of some behaviours. These give guidance to staff and ensure that information is recorded that informs future decisions and actions. All service users have key-workers with whom they have an amount of designated one-to-one time every week. Minutes from reviews and service user meetings show that people are fully involved, as far as their abilities allow, to make decisions about their care and choice of activity. Service users are supported to manage their own finances where possible. A sample of risk assessments were seen and these were up to date and appropriately reviewed. Certain information is also provided in symbol from to increase the understanding and involvement of service users. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 &17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home support and encourage service users to live a lifestyle that is based on individual choice and aspiration. EVIDENCE: The records show that over the previous several months staff have supported an increasing number of activities in and away from the home. Staff commented that this due to the rota being reorganised more flexibly and the clearer identifying of social and leisure activities that service users may wish to undertake. Trips undertaken included cinema, pubs, music therapy, pottery and a Wild Life Park. Service users interviewed expressed satisfaction with the range of activities and outings they are supported to undertake. All service users have a weekly timetable or routine that they follow in terms of their daytime activities. This is primarily attendance at a day centre, but one person also undertakes work experience a couple of days per week. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 12 Records show regular contact and visits from families. Service users spoken to were very positive about the building work and appeared well informed about the development of the environment. On one day of the inspection service users were working with the staff to prepare an evening bar-be-que. People were observed working cooperatively and interacting in a relaxed and respectful manner with the staff team. The kitchen was well stocked with fresh and frozen produce, and all of which were correctly labelled and stored. The menus show that choice is provided and that staff have a good knowledge of the likes and dislikes of the service users. Service users were observed preparing their packed lunches for the following day. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Health needs are closely monitored and appropriate professional input provided to meet the needs of the service users, and provide advice and guidance for the staff team. EVIDENCE: The care plans detail the personal care and support that is required. They also detail any personal wishes or preferences that people have in terms of how the care is delivered. The records show regular visits to health professionals for routine checks as well as for other issues. Some staff have undertaken training in area dementia, as this is an increasing issue for two service user within the home. The home have sought advice and guidance in this area and have put certain management strategies into place to support the people concerned. All medication was correctly stored, and records were accurate and up to date. The files contain the dates when medication has been reviewed and also information about possible side effects. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 14 Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 15 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are encouraged and supported to express their opinions on all aspects of their care. The home has appropriate behaviour management plans in place to protect service users. Further training in Adult Protection would provide a greater knowledge base in this area for the staff team and improve the protection measures being provided. EVIDENCE: The home has developed and put in place behaviour management plans for two service users. These plans aim to support people to maintain their friendships without placing anyone at risk. These have so far been successful and both service users were observed as being comfortable and relaxed in their home. The home have guidance in place for the approach for staff to take for one person who can occasionally be verbally abusive. This has been done in conjunction with the Community Learning Disabilities Team. A recommendation has been made under the staffing standards that the home consider whether there would be any benefit in accessing additional Adult Protection training that is available locally. There have been no complaints made to the home during the previous twelve months. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 16 Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 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 the following standard(s): 24&30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are provided with a clean, homely and comfortable environment. EVIDENCE: At the time of the inspection the home were in the process of having extensive building work undertaken which will provide a significantly improved environment for the service users. Appropriate risk assessments have been completed and put in place whilst this work is being carried out. All parts of the home seen were clean and hygienic but a fuller inspection of the environment will be undertaken when the work has been completed. The building work has meant that there is a change to the access arrangements for the rear of the property. A recommendation is made that the home consult with the fire safety department on the security arrangements for the side gate to ensure that fire evacuation and safety procedures are not affected. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service user’s needs are met by a well-organised and motivated staff team. Service users are protected by the home’s recruitment policy. The undertaking and completion of NVQ training would further develop the staff team. EVIDENCE: Staff were observed communicating effectively with a service user who has limited hearing. The home makes use of signs and symbols and it was evident that staff on duty had a good understanding of the person’s needs and difficulties. Staff were also observed organising shopping, cooking, medication and plans for the weekends. Service users and staff were observed interacting in a positive and respectful manner. Service users spoken to were very positive about the staff team and management. At this visit, and as observed at previous inspections, there is evidence of caring and professional relationships and of a positive and motivated staff team. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 19 Staff have completed the required statutory training and also a number of courses run by the Mencap Society. Courses have included Dementia awareness and Person Centred Planning. All but the most recently appointed staff have also attended a Mencap course on Protection, though for some this was several years ago. A recommendation is made that the home considers whether staff require an update of this training. Two care staff are currently enrolled to undertake NVQ training, and NVQ training is also being completed by the Manager and Deputy. However no staff have yet attained the award. The standards recommend a minimum of 50 staff qualified and the home must continue to work towards this. The home has had low levels of staff sickness. There has been one new staff member appointed since the last inspection. Staff files were examined and these contained all the required information and documents. Staff are receiving formal recorded supervision once a month. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39&42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well run and managed home, which would be further improved by the provision of a permanent registered manager. EVIDENCE: The home is well run and managed by the acting manager, who is going through the registration process. Staff were very positive about the support and guidance they receive from the management team. Service users are consulted on all aspects of the running of the home and are involved in decision making as far their abilities and interest allows. The home receives regular monthly visits from the area manager, who supervises the manager and also completes the Regulation 26 visits. Copies of these reports are kept at the home. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 21 The home has completed a Quality Assurance exercise with the service users, which involved the use of an advocate. The manager has completed an action plan covering areas they wish to progress and has also had an annual appraisal from their line manager. The development plan for the home does not contain a lot of specific detail but identifies the areas of Health and Safety, maintenance, records and staff training which the home intends to make changes in. The manager has completed annual appraisals on all but one of the care staff. All health and safety checks had been completed and recorded. All fire equipment has been serviced and all testing has been completed and recorded. Staff are up to date with the required statutory training. Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 23 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 Standard YA37 Regulation 8 Requirement The home must register it’s manager Timescale for action 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA23 YA6 YA42 Good Practice Recommendations The home should consider accessing Adult Protection training. The home should consider recording more detail in the goals and objectives section of the care plan review The home should consult with the fire department regarding the security of the side gate to the rear of the property Caldicott House DS0000016394.V291557.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Gloucester Office Unit 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 DS0000016394.V291557.R01.S.doc Version 5.1 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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