Inspection on 16/01/06 for Cavendish Care

This inspection was carried out on 16th January 2006.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cavendish Care 30/01/08

Cavendish Care 19/09/06

Cavendish Care 22/08/05

Cavendish Care 19/08/04

Cavendish Care 15/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Cavendish Care Cavendish care 10 Cavendish Road Redhill Surrey RH1 4AE Lead Inspector Deavanand Ramdas Announced Inspection 16th January 2006 10:00 Cavendish Care DS0000047704.V270090.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 Cavendish Care DS0000047704.V270090.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. Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cavendish Care Address Cavendish care 10 Cavendish Road Redhill Surrey RH1 4AE 01737760849 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) Cavendish care Mrs Sonia Beryl Williams Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th August 2004 Brief Description of the Service: Cavendish Care is located in Cavendish Road, Redhill, Surrey within walking distance of the local town centre and public amenities. The home provides personal care only to six adults with a learning disability. The accommodation is on three floors accessed by stairs. The services on offer include a communal lounge, a large kitchen/diner, a conservatory, a laundry and adequate bathing and washing facilities. Bedrooms have en-suite facilties. The home has a well maintained back garden that is safe, secure and easily accessible. The front of the property has a small garden and a driveway. Private parking is available. The home is nicely decorated with good quality furnishings and fittings. The registered manager is Sonia Williams and the registered provider is Cavendish Care. Cavendish Care DS0000047704.V270090.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 carried out by one inspector over a period of four hours. A full tour of the premises took place, staff and service users were spoken to, and documents and records were inspected. The inspector noted some service users at the home had communication difficulties and judgements made about them were based on their mood and behaviour during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home needs to improve staff training in relation to medications to promote the health of service users and care planning concerning the ageing, illness and death of service users must be developed to ensure ageing, illness and death are handled as the individual would wish. National Vocational Qualification (NVQ) training needs to improve to ensure the home is able to meet the targets specified in the National Minimum Standards (NMS) and a copy of the business/financial plan must be sent to the commission for information. Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 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. Cavendish Care DS0000047704.V270090.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 Cavendish Care DS0000047704.V270090.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): 1,4. The homes statement of purpose and service user guide are good providing details of the services the home has to offer enabling an informed choice to be made about admission to the home. The arrangements for admission to the home are satisfactory ensuring service users have an opportunity to visit and “test drive” the home before admission. EVIDENCE: The home has a statement of purpose and service user guide that was reviewed and updated in 2005 and contained information about the aims, objectives and philosophy of the home. The service user guide had information about the services and facilities the home offered and was in a widget format to make the information accessible to service users. The home had an admission and placement policy and the manager stated the home offered prospective service users the opportunity to visit the home, meet service users, staff and view the home. The inspector noted the home offered a trial period following admission to the home which was reflected in service users contracts. Cavendish Care DS0000047704.V270090.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): 8 &10. The systems at the home ensure service users are offered opportunities to participate in the day-to-day running of the home. Policies on confidentiality are adequate ensuring information about service users are appropriately handled. EVIDENCE: The manager stated the home offered opportunities for service users to participate in the day-to-day running of the home and some policies and procedures were in a widget format to make the information understandable to service users. The home had a policy on confidentiality and procedures for dealing with a breach of confidentiality by staff. The manager stated confidential information about service users is shared on a need to know basis and the inspector noted service users individual records were accurate, secure and stored confidentially in a locked cabinet in the manager’s office. Cavendish Care DS0000047704.V270090.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): 11,15,16&17. The arrangements for personal development is adequate ensuring service users have opportunities to maintain and develop emotional skills. The home offers service users the opportunity to have appropriate family relationships. The daily routines at the home are satisfactory ensuring service users rights are respected. Meals at the home are adequate and offer service users enjoyable meals of their choice. EVIDENCE: The manager stated service users have opportunities for personal development and remarked one service user has anger management training and attends counselling to build his confidence and self-esteem which was reflected in the service user care plan. The manager stated the home supported service users in maintaining family relationships and friendships and the home had a visitor’s policy which reflected service users can choose whom they see and when. Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 11 The home had a policy on dignity and observations confirmed the manager and deputy manager knocking on doors before entering service users’ bedrooms and staff addressed service users by their preferred names. The home had menu plans which were in a widget format and displayed in the kitchen for information. The senior support worker stated service users are involved in planning the menu and help prepare and serve meals and commented “it is their menu not ours”. The menu was sampled and it reflected well-balanced healthy meals with plenty of vegetables and fruits. A service user stated “I like the food, I like sausages and chips” which was reflected on the menu. Cavendish Care DS0000047704.V270090.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&21. The arrangements for managing medications need to improve to promote the health of service users. The arrangements for managing the ageing, illness and death of a service user need to improve to ensure it is handled as the service user would wish. EVIDENCE: The home had a policy on medications and a service level agreement with a local chemist which supplied medications on a monthly basis. The home provided a locked cabinet for the safe storage of medications and medication record sheets had a recent photograph of the service user and were dated and signed by staff. The home kept a record of medications received at the home and medications returned to the pharmacy which were dated and signed by staff. The home had a bereavement policy and staff had training in managing emotion in change, loss and bereavement. The manager stated the home sent bereavement packs to families to obtain information about ageing, illness and death of service users and the response from families were not good. Care plans did not reflect the wishes of service users concerning ageing, illness and death and a requirement has been made in this area to ensure it is handled with respect and as the individual would wish. Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The complaint process at the home is satisfactory with complaints information available to staff, service users and relatives. EVIDENCE: The home had a complaint policy dated 2005 which was in a widget format to make the information understandable to service users. The manager stated the home had received no complaints since the last inspection which was reflected in the complaints register. During a meeting staff stated they were aware of the complaints policy. Cavendish Care DS0000047704.V270090.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): 24,26,27&28 The management arrangements at the home ensure service users live in a homely, comfortable and safe environment. Bedrooms are adequate and promote the independence of service users. Toilets and bathrooms are adequate ensuring sufficient privacy to meet the individual needs of service users. Shared spaces are satisfactory ensuring service users have accessible shared spaces for activities and private use. EVIDENCE: The property is in keeping with the local community and the home is close to public amenities. On the day of the inspection the home was clean, safe, comfortable and well presented with adequate heating, lighting and ventilation. Service users had bedrooms with en-suite facilities which were spacious, nicely decorated and personalised with sufficient storage space and good quality furniture, fittings and flooring. One service user had maps and guides in his bedroom to meet his personal interest and another service user with IT skills had a computer in his bedroom for personal use. Observations confirmed service users had unrestricted access to bedrooms which were lockable and it was positive to note the home had exceeded standard 26 of the National Minimum (NMS) as bedrooms promoted the independence of service users. The home had adequate toilets and bathrooms which were lockable for privacy Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 15 and one toilet was located near the dining area and lounge which was easily accessible. The home has a communal lounge which is nicely furnished with good quality furniture and fittings and a conservatory which is used for social activities and relaxation. There is a large garden which is well maintained, private, secure and easily accessible. Cavendish Care DS0000047704.V270090.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): 31,32&35 The management of staff is satisfactory ensuring staff have job descriptions and understand their role and responsibilities. The training of staff needs to improve to ensure the home meets the target set for National Vocational Qualification (NVQ) training. The home has a training and development plan ensuring staff fulfil the aims of the home and meet the needs of service users. EVIDENCE: The home had a management structure and staff working at the home have job descriptions to ensure they understand their responsibilities which are linked to the aims of the home and service users’ needs. Staff working at the home have been issued with the General Social Care Council (GSCC) code of conduct and the home operated an on-call system to provide advice, additional support and expertise to the staff team. During discussions a member of staff stated “I am senior support worker and a key worker”. The home had a training plan dated 2006 which outlined the training opportunities on offer to staff and the inspector noted staff had training in autism, sign language, preventing and responding to aggression and had completed the learning disability award framework (LDAF) training which are skills necessary for the job they are expected to do. Observations confirmed staff were good listeners and were accessible to, approachable by, and comfortable with service users. A review of training records confirmed the Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 17 home had not met the targets set for National Vocational Qualification (NVQ) training and a requirement has been made to address this shortfall. The home had a structured induction programme and monitored progress using an induction checklist. The inspector sampled an induction file and noted the induction programme was completed, dated and signed by the supervisor and supervisee. Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 18 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): 39,40,41,42&43. The systems for quality assurance are satisfactory ensuring service users participate in the development of the home. Policies and procedures are adequate ensuring the rights and best interests of service users are safeguarded. Recording keeping is satisfactory ensuring the rights and best interests of service users are safeguarded. The systems for health and safety are adequate ensuring the health, safety and welfare of service users are protected. The overall management of the service is satisfactory, however the home needs a business or financial plan to ensure the financial viability of the home. EVIDENCE: The home had a policy on quality assurance and used questionnaires to obtain feedback about the home from relatives and outside agencies. The manager stated the home had regular meetings with service users to consult them about the day to day running of the home. Policies and procedures are regularly reviewed and updated and are available for information. The inspector noted some local policies in the home were written by service users Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 19 to reflect their needs which is good practice and service users’ records were up date, accurate and confidentially stored in a locked cabinet. The home had a policy on health and safety and staff had attended a training course in health and safety, first aid and fire safety. The home had a current gas certificate, small appliances test certificate, fire alarm test certificate and a legionella test is being carried out. Food was correctly stored and the fridge and freezer temperature was within normal limits. The home had a certificate of employers liability insurance and the manager stated the home is involved in the business planning process and business plans were kept at head office. The inspector noted the home did not have a copy of the current business or financial plan for inspection and a requirement has been made to address this shortfall with a copy of the business plan sent to the commission for information to ensure financial viability and accountability of the home. Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X 3 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 4 3 3 X X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cavendish Care Score X X 2 2 Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 3 2 DS0000047704.V270090.R01.S.doc Version 5.0 Page 21 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 NMS-YA21 Regulation 13 (c) Requirement The registered person must ensure staff have accredited training to manage and administer medications to promote the health of service users. The registered person must ensure care plans have a section concerning the ageing, illness and death of a service user to ensure it is handled as the service user would wish. The registered person must produce a staff action plan with timescales to meet the targets set for National Vocational Qualification (NVQ) training to ensure service users are supported by qualified staff. The registered person must ensure a copy of the business/ financial plan is sent to the commission without delay for information. Timescale for action 01/03/06 2 NMS-YA22 12(3) 01/03/06 3 NMS-YA32 18(1)(a) 01/03/06 4 NMS-YA43 25(3)(c) 20/02/06 Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 22 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 No recommendations were made following this inspection. Cavendish Care DS0000047704.V270090.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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