Inspection on 04/10/05 for Cathedral View

This inspection was carried out on 4th October 2005.

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

The inspector found 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

Cathedral View 22/12/06

Cathedral View 15/02/06

Cathedral View 23/03/05

Cathedral View 02/12/03

Cathedral View 18/11/02

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

CARE HOME ADULTS 18-65 Cathedral View Archdeacon Street Gloucester GL1 2QX Lead Inspector Kath Houson Announced Inspection 4th October 2005 13:00 Cathedral View DS0000032190.V255912.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 Cathedral View DS0000032190.V255912.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. Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cathedral View Address Archdeacon Street Gloucester GL1 2QX 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) 01452 303248 01452 505073 debbie.ewers@gloucestershire,gov.uk Gloucestershire County Council Mrs Deborah Ewers Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9) of places Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd March 2005 Brief Description of the Service: Cathedral View is a nine-bed unit, which provides planned and emergency respite care. The facility is owned and operated by Gloucestershire Social Services and would accept referrals countywide. The premises is situated close to Gloucester Cathedral and is within walking distance of the docks and town centre. The home provides respite care for adults with learning disability. The accommodation has equipment and adaptations to meet the needs of service users with mobility difficulties and can accommodate one wheelchair user at a time. The premises consist of single well-furnished rooms on both upper and ground floors and residents have the use of a lift. There also a separate quiet lounge, landscaped gardens to the rear of the building, a dinning hall and recreation area. There is a well-maintained and organised laundry room. There is plenty of quiet space within various parts of the building for residents to have time alone or with visitors. The home maintains and encourages residents to continue to participate and attend day centres as part of their normal daily routine. Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place one afternoon in October 2005. The manager was available throughout the inspection and able to assist and provide all relevant documentation on request. An informal and short discussion was conducted with residents. Three resident records were case tracked. Ten of the core standards were assessed and included examination of records and a tour of the environment. What the service does well: What has improved since the last inspection? The administration of medication has improved since last inspection. A system has been developed around; dispensing, administration, and disposal of medication to ensure that opportunity for errors are kept to a minimum. Staff training around the administration of medication has been completed and is evident that fewer drug errors have occurred. The system of two staff to administer medication is seen to be good practice. The manager is continually developing the service in order to sustain high quality and consistency. Cathedral View DS0000032190.V255912.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. Cathedral View DS0000032190.V255912.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 Cathedral View DS0000032190.V255912.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): 1 The statement of purpose needs some minor review to ensure that guests’ have up to date information about the running of the home. EVIDENCE: The statement of purpose had not been reviewed recently. The manger did mention that the statement of purpose would only be reviewed and or changed if there was any transformation within the service or the home. However, there have been staff changes that would require the statement of purpose to be reviewed and updated to reflect changes in the staff structure. Furthermore, the home has reviewed a number of policies and procedures that are included in the statement of purpose. The home is able to accommodate, people with physical disabilities and this will need to be reflected in the category of registration. The home will need to submit a variation form. Cathedral View DS0000032190.V255912.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 and 9: Care plans and record keeping was generally good and protect Service users’ EVIDENCE: Three service user care plans were examined. Evidence demonstrated that the care plans were individualised, with good accounts of daily events, and risk assessment, which were equally individualised and documented for each service user. The home has a response protocol that will be activated if unexplained absences of service users’ were to occur. The service users’ are encouraged to live an independent life style and are given support to achieve safety and independence. The effective quality assurance and monitoring systems was positive and demonstrated good practice. Shortfalls were addressed promptly taking into account service users and their representatives. The manager was reminded that if a service user has a particular life threatening risk, for example risk of choking staff must ensure that a robust risk assessment is documented. Service users were encouraged to have bi-monthly meetings; minutes of the meetings were documented and available. The meetings gave the service Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 10 users’ an opportunity to be involved in the daily planning of their lifestyle, and to enhance continued independence. Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 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): 16 The home provided a range of varied activities and opportunities to meet the identified needs of the service users’ EVIDENCE: The information on the care plans demonstrates service users preferences, routines, and activities to encourage independence and daily living. Moreover service uses have the choice to attend day centres and join in appropriate leisure activities. The home has a protocol in place for a listening device, which is used with the permission of the service user. The home provides a range of home entertainment located in-house in the games room that also has an electric organ and snooker table. The manager states that the home has regular links with family and representatives. The evidence was reflected via feedback forms from guests’ and representatives; any issues were promptly addressed. Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 12 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): 20 Previous inspection highlighted a number of medication errors. These have now been resolved with the assistance with the pharmaceutical inspector, reducing the likelihood of errors to occur. EVIDENCE: The manager states, that a system has been developed for the administration, dispensing and disposal of medication within the home. All medication entering the home is accounted for and documented. The home will only accept medication in its prescribed bottles or containers to be used by the guests’ during their stay. Two trained members of staff administer medication, with clear signatures applied to relevant medication records. Medication profiles for all service users include a current photograph, with consent forms. In addition to this the medication documentation formed a coherent and consistent evaluation of the service user as a whole. Medications were housed in a locked cupboard and the home has a recent copy of the British National Formula (BNF). The manager also states that all staff are trained to handle the medication within the home and the local pharmacist supplied that training. This is a positive improvement and demonstrates good practice. Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 13 Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 14 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): Standard 22 & 23 were main focus on this occasion The home implements policies and procedures to protect service users and to ensure that the views of service users’ are taken on board EVIDENCE: Feedback forms demonstrate good and positive comments from both service users and family/representatives. Problems were dealt with promptly. The last complaint was in 2003. Documentation for the complaints log was seen; no recent complaints had occurred on the whole individuals were content with the provision of the service. Service users were encouraged to have bi-monthly meetings. A set agenda was arranged to discuss any matters arising. Minutes of the meetings were seen on this occasion. Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 15 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; 25,26,27,28 29, and 30. The home continues to maintain high environmental standards that meet the needs of the guests during their stay. EVIDENCE: Service users live in a clean safe comfortable environment; the décor fixtures and fittings are of good quality. The home is clean and free from any offensive smells. Bedrooms were clean and tidy but not personalised due to the nature of the home being a respite centre. Specialist equipment is maintained and checked regularly with relevant policies and procedures in place. There is a specialist bedroom with en-suite, which has been adapted for physical disability. The home is well placed to access all of the facilities in Gloucester City Centre area, and has an enclosed landscaped garden to rear of the premises. The laundry room was clean and tidy with organised baskets for every occupied room. Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 16 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, 34, and 35 There was a robust staff training procedure in place, to ensure that skills were updated regularly, to meet the needs of service users. EVIDENCE: The home has a strong team of carers who are qualified to meet the needs of the service users. There are four first aiders, all staff have NVQs, all staff have basic training in fire, food handling, administration of medication, health and safety. A staff-training matrix was seen with future dates arranged. Additionally the manager is organising a training week for all staff, to encourage team building and incorporate night staff into team building sessions. Staff files were sampled which include the most recent appointment. The file contained; two references, application form, CRB, proof of identification with photo ID, copy of terms of conditions of employment. The manager was reminded that there must be no gaps in employment and that full employment history must be obtained, with written reason for leaving previous employment. Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 17 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): This standard was not assessed at this inspection. EVIDENCE: Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 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 2 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cathedral View Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000032190.V255912.R01.S.doc Version 5.0 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 3 Standard YA1 YA6 YA9 Regulation 6(a) and (b) 17 (1) (a) 13 (4) (c) Requirement Timescale for action 31/01/06 Review Statement of Purpose and forward copy to the CSCI Every care plan must include a 31/01/06 photograph of the service user Risk assessment to be completed 30/11/05 for the risk to specific service user regarding swallowing reflex 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 Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 Page 20 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 Cathedral View DS0000032190.V255912.R01.S.doc Version 5.0 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. 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. 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