CARE HOME ADULTS 18-65
Cantley House 12 Woodcross Avenue Cantley Doncaster South Yorkshire DN4 6RU Lead Inspector
Sarah Powell Key Unannounced Inspection 18th January 2007 09:00 Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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 Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Cantley House Address 12 Woodcross Avenue Cantley Doncaster South Yorkshire DN4 6RU 01302 367672 P/F 01302 367672 brew.active@btinternet.com 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) Active Care Homes Ltd Steven Light Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered manager will manage two homes until 1 April 2007 while a new manager is being trained to manager Bennethorpe House. New registration Date of last inspection Brief Description of the Service: Cantly House is a large four bedroom detached house set in a residential area of Cantly near Doncaster. It is registered for three service users with a learning disability ages 18 – 65. The home has a large through lounge, a kitchen diner, three bedrooms for service users two with en-suites and a communal bathroom. The fourth bedroom is used as an office and staff sleep room. The home has a rear garden and a paved front providing adequate parking. The fees at Cantly house at the time of the inspection were £1,850.00 although this varies depending on the needs of the service users. These fee charges only applied at the time of inspection, more up to date information may be obtained from the home. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes first inspection since registration in July 2006 all standards were inspected at this inspection. The inspection was unannounced and took place over two days on 18th January 2007 at 09:00 and finished at 15:45 and on 14th February 2007 at 14.15 and finished at 16.00 the second day was to see service users. As part of the inspection process the inspector spoke to 1 service user, 1 staff member and the manager. A tour of the building took place, observing the standard of the environment, staff and service users. A number of records were examined these included medication, service users care plans, recruitment, training, quality assurance systems, and health and safety records. Feedback was given to the Manager when the visit was completed. What the service does well: What has improved since the last inspection? What they could do better:
The service users contracts were not available at the home, this was discussed with the manager. He will ensure a copy is available in the home and that each service user has a statement of terms and conditions, as these had not been provided. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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 Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Good detailed assessments are carried out for all service users to ensure their needs are met. Contracts were not available and the statement of terms and conditions still need to be provided. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 9 EVIDENCE: A statement of purpose and service user guide was available in the home and had been made available to the service users. These had not been updated since the registration of the home and needed to be reviewed and updated. The service user had been fully assessed prior to moving into Cantly House to determine that their needs could be met. Introductory visits had been carried out before making decisions, this was clearly seen in the service users plans of care. Introductory visits were taking place for a perspective service user to ensure his needs could be met and that he was able to live with the existing service user. The service users contracts were not available at the home, this was discussed with the manager. He will ensure a copy is available in the home and that each service user has a statement of terms and conditions, as these had not been provided. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual needs and choices of service users are met. EVIDENCE: One service user was case tracked, as part of the inspection process, there was a comprehensive plan of care, which had identified all the service users needs and how to meet them. Person centred plans and health action plans had been commenced and were being updated as the staff got to know the service user. It was evident from talking to staff and the service user that service users are able to make decisions, are given choices and are able to take reasonable risk as part of an independent lifestyle, which includes attending collage. Staff were also aware of the need for confidentiality.
Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12,13, 14, 15, 16 & 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users take part in appropriate activities, have opportunities for personal development and their rights are respected. EVIDENCE: Staff support service users to have relationships with family and friends, service users had contact with family and friends. The service user spoken to said he had regular contact with his family they visited him at his new home and he also went to their homes. Staff spoken to were aware that relationships had to be appropriate to protect service users, who due to their learning disabilities may not always be able to make an informed decision. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 12 Service users were offered a healthy diet, service users did the shopping with a support worker and prepared their meals with assistance. The service users also ate out, particularly if they were going out doing an activity. The manager and staff are looking at further education prospects for the service user, he told the inspector that he wanted to go to Doncaster collage and would like to do a computer course. A number of courses had been identified and staff were in the process of choosing an appropriate course with the service user. Appropriate leisure activities were provided daily for the service users and the service user said he enjoyed the activities and he was able to choose what activities he wanted to do. The daily routines within the home had been observed to be very flexible and the service user confirmed this. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care needs of service users are met and personal support is provided in the way service users prefer. EVIDENCE: Service users are able to maintain their own personal care with support from the staff, this is documented in the plans of care. The service user chose their own clothes and hairstyle to reflect their personality and the service user was dressed appropriately for their age. A clothing budget is given to each service user every year to enable clothes to be replaced regularly. Health care needs of service users are maintained, all service users are registered with a GP. All access local dentists, chiropodists and opticians. They also receive an annual health check from their GP’s. This was all documented in the care plan. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 14 The needs of the service users regarding ageing and illness had not been addressed. The manager was aware this was required and was going to address this at the next review, to ensure service users needs and wishes are documented. Medication polices and procedures in the home were very good all medication was documented on arrival, was documented when administered and disposed of. Medication was appropriately stored. All staff that administer medication had successfully completed accredited medication training to protect service users. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good complaints procedure and robust procedures to protect service users from abuse. EVIDENCE: There is a clear and effective complaints procedure, which includes set timescales. The complaints procedure also states that the Commission for Social Care Inspection can be contacted at any time. The home had received no complaints since it was registered. The home has a good adult protection policy that clearly defined different types of abuse and staff were well aware of different types, they were also aware of the importance of whistle blowing. The Doncaster council policy for protection of vulnerable adults was also available in the home. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Good environmental standards are maintained Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 17 EVIDENCE: The home is suitable for its stated purpose it is safe and comfortable. The standard of cleanliness throughout the home was excellent and all routine maintenance was carried out. The service user showed the inspector his bedroom and it had the furniture and fittings that they had requested including a music deck and speakers on the wall meeting their needs, he said he was very happy with what he had been given. The home has a large through lounge with patio doors onto a decked area, which was well furnished with television and DVD. There was a large kitchen diner and a garage for storage. The home had small gardens to the front and rear that are well maintained Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by an effective team and protected by the homes recruitment practices. EVIDENCE: A selection of staff training files were seen, records were excellent and all training had been carried out to ensure service users needs are met. The manager has also implemented a rolling programme of training to ensure staff are regularly updated, to ensure service users needs are met by appropriately trained staff. The home operated a thorough recruitment process. A selection of personnel files were looked at they all contained all the required information and checks to ensure the service users are protected. All staff had a clearly defined job description, signed and placed in their personal files. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 19 Staff were enrolled on NVQ training to ensure that 50 of care staff had achieved NVQ level 2 or above. The staffing structure in the home was very good with clear lines of responsibility, staff were in sufficient numbers with complementary skills to support service users. The staff had regular supervision to ensure they were competent to carry out their jobs and records of these were seen in the files. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 & 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run with health and safety promoted and maintained. EVIDENCE: The registered manager is qualified and experienced to run the home, he had registered to commence his Registered Managers Award and hopes to be completed by August 2007 gaining more knowledge to ensure a well run home. The manager creates an open, positive and inclusive atmosphere this was observed during the inspection. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 21 The home has got good quality monitoring systems based on seeking views of service users, and Regulation 26 visits are carried out to ensure service users views underpin development in the home. The home has good policies and procedures in place to safeguard service users and staff. The manager has also implemented some new policies since the home opened ensuring all areas of work were covered. The home has a good health and safety policy and all staff were receiving an update in health and safety on the day of the inspection, ensuring the safety of the service users. The maintenance records for electrical safety, Portable appliance testing, legionella, and gas were all provided when the home was registered ensuring the safety of the service users. Fire checks, water temperatures and environmental safety checks including equipment and machinery were seen during the inspection all were satisfactory. The providers have implemented a business and financial plan for the home, however this is very general. There is a need to produce an annual development plan with more detail and include all aspects of the home reflecting aims and outcomes for service users. Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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 2 2 3 3 3 4 3 5 1 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 4 25 4 26 4 27 4 28 4 29 3 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 2 3 3 3 3 Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA1 Regulation 6 Requirement The statement of purpose and service users guide must be updated to reflect the home now it has service users and a full staff team. The contracts must be available at the home and each service user must have statement of terms and conditions. An annual development plan must be produced. Timescale for action 01/04/07 2. YA5 5 01/04/07 3. YA39 17 01/04/07 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 Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Cantley House DS0000067975.V327371.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!