Inspection on 19/11/05 for Caldicott House

This inspection was carried out on 19th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Caldicott House 10/05/06

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 Unannounced Inspection 19th November 2005 10:00 Caldicott House DS0000016394.V267485.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 Caldicott House DS0000016394.V267485.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. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 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 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) Royal Mencap (Housing & Support Services) Mrs Suzanne Harris Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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.V267485.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 3 hours on a Saturday morning and was the first time the home has been inspected at a weekend. The inspector met with one staff member and all of the service users. A brief inspection of the communal areas was completed as well as the exterior of the property. A sample of personal files were examined along with other records and recording. The main focus of this visit was the staffing cover provided and the activities that were being supported through the weekend period. This was the second inspection this service has received during this inspection year. All of the core standards were inspected and met at the previous visit. What the service does well: What has improved since the last inspection? The home has improved the flexibility of the weekend staffing cover arrangements to better meet service users needs. No other significant improvements were identified at this unannounced visit but the home continues to provide a consistently good standard of care. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 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 DS0000016394.V267485.R01.S.doc Version 5.0 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.V267485.R01.S.doc Version 5.0 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): None of these standards were inspected during this visit. EVIDENCE: There have been no admissions to the home during the previous 12 months. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 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): 6,7,8 & 9 The home has a care planning system in place that identifies and meets the needs of the service users. EVIDENCE: Care plans examined were up to date having been regularly reviewed. Staff records daily events and observations in the personal diaries and records also showed that people are supported to make decisions about their care and daily/weekly routines. One service user has a behaviour-monitoring chart in place and this showed that there had been no recordable incidents for several months. The risk assessments in place were all up to date with appropriate reviews being recorded. On the morning of the visit people were involved in domestic chores such as preparing their breakfast, cleaning and laundry tasks, planning for lunch and taking out the empty milk bottles. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 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 the following standard(s): 11,12,13,14,15,16&17 Service users are supported to follow a lifestyle based on choice and their individual abilities. Service users contribute to the daily running of their home. EVIDENCE: On the morning of the inspection there was one staff member on duty but this was to accommodate extra staffing in the afternoon when a group trip out was planned to see the switching on of the Xmas lights. The staffing arrangements allowed for people to attend or remain in the house. One person was collected by relatives for a trip out into town. Another service user described the party they are planning for a few weeks time and another described a shopping trip planned for later in the day. There was a relaxed atmosphere within the home with staff and service users interacting in a positive and respectful manner. The staff member on duty explained that trips to church are still supported if required but the service user concerned often now chooses not to attend. Service users were also watching television and listening to music in their rooms. One person contacted the local radio station to arrange to have a request played on the radio. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 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 the following standard(s): 18&19 The home has systems in place for the monitoring of health needs and for recording how these needs are met. EVIDENCE: The personal files seen showed that all medical checks were up to date and the recording showed staff are monitoring health needs and taking appropriate action such as referrals to specialist services. Staff have received additional training in the areas of challenging behaviours and dementia care. Individual files give details of the support required and how this should be provided. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 Page 12 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 The home promotes an open culture that helps safeguard vulnerable people and encourages them to express their opinions. EVIDENCE: The home has a complaints procedure in place that is appropriate to the needs of the service users. Service users appear confident in their home and are able to raise concerns or issues with staff. Service users were observed giving opinions and comments to the staff about their planned activities for the weekend. Recording also showed staff had responded to issues raised by service users. An impression was given to the inspector that one service user with limited communication was able and confident to be assertive about matters that concerned them. Standard 23 were not inspected in detail but an incident had been recently recorded were a service user had assaulted another service user. It was unclear as to the true nature of the incident as it was seemingly out of character and between two people who are generally considered to have good relationship. At the time of the inspection they were observed interacting in a friendly and relaxed manner and there have been no subsequent concerns since this incident. The Commission had not yet been informed of this matter as it should have been but it was explained that this was because the acting manager had been on leave when it had occurred. Subsequent to the inspection the home supplied the correct notification and also an action plan containing a risk assessment that had been completed in conjunction with the homes area manager. A requirement has been made that the home ensure that all staff are aware of their obligations under Regulation 37 in the absence of the manager. The regulations state that notification should be supplied “without delay” and staff Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 Page 13 should be aware that the initial contact could consist of a phone call with written details being supplied at a later date, possibly when the manager returns from leave or absence. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 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 the following standard(s): 24,27,28&30 The home is comfortable and homely and generally well maintained and decorated. Work needs to be completed in the front area of the home to improve the appearance and promote the safety of the service users. EVIDENCE: The communal areas were inspected and these were generally clean and decorated to a reasonable standard. Service users spoken to expressed satisfaction with their bedrooms and also the home generally. The repairs required to the external paintwork have been completed. The home no longer has access from the rear of the building due to the construction of some new houses and a driveway has been made onto the front area of the house. At present this consists of a narrow space that has been made in the wall. This makes getting in and out fairly difficult. A fact made more difficult due to the house being situated on a busy road. This work needs to be completed properly so that entering and exiting the parking area can be done safely. Also neither of the two front openings currently have any sort of gates. These need to be provided to ensure privacy and promote the appearance of the building and also to help ensure the safety of service user using the front garden. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 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 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 The home has an established staff team that understand people’s needs and the rotas are organised to accommodate the choices that are made. EVIDENCE: The staffing cover for the weekend was organised to accommodate the various activities that were planned. Records showed that normally there would be two staff on duty on a Saturday morning but that this had been rearranged to support the activities that were planned for later in the day. Double cover is provided during the day over most weekends. There are currently no vacancies at the home and staffing records were not examined as part of this inspection. An additional staff member has been recruited to work at weekends to support specific activities. A relief care worker was on duty at the time of the visit and they appeared well informed about the home and the service users and were observed meeting needs and relating well to service users. They have worked regularly at the home for sometime as the home has its own group of relief workers. The staff group have recently undertaken a days training around Challenging Behaviour that was provided by the psychologist from the local CLDT. Staff have also received training in dementia care. Records show that regular staff meetings take place with a range of issues being discussed and a variety of information being shared. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 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 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): 42 The home provides a safe environment for the service users with systems in place to monitor and maintain standards. Work needs to be completed in respect of the front parking area to ensure the safe arrival and departure of vehicles to the property EVIDENCE: All fire safety checks and maintenance have been completed. The home has a Health and Safety monitoring file where all checks are recorded, this was examined and was observed as up to date. All staff are up to date with the required statutory training. A requirement has been made in relation to standard 42 concerning the entrance to the parking area. Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 Page 17 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 X X X X Standard No 22 23 Score 4 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 2 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Caldicott House Score 4 3 X x Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000016394.V267485.R01.S.doc Version 5.0 Page 18 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 3 Standard YA23 YA42 YA42 Regulation 37 13(4a) 23(2b) 23(2o) 13(4)(a)& 23(2)(o) Requirement Timescale for action 31/12/05 The home must ensure that staff are aware of the requirements of Reg 37 notifications The home needs to ensure that 31/01/06 the front parking area can be safely accessed and vacated The home must provide gates for 31/01/06 the front of the house RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Caldicott House DS0000016394.V267485.R01.S.doc Version 5.0 Page 19 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.V267485.R01.S.doc Version 5.0 Page 20 - 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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