Inspection on 22/08/05 for Cavendish Care

This inspection was carried out on 22nd August 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

Cavendish Care 30/01/08

Cavendish Care 19/09/06

Cavendish Care 16/01/06

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 10 Cavendish Road Redhill Surrey RH1 4AE Lead Inspector Deavanand Ramdas Unannounced 22 August 2005 09:00am nd 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 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 Stationary 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 H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Cavendish Care Address Cavendish Care 10 Cavendish Road Redhill Surrey RH1 4AE 01737 760849 Telephone number Fax number Email 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, Berry House, 58 High street, Bletchingly, Surrey, RH1 4PA Mrs Sonia Beryl Williams Care Home (CRH) 6 Category(ies) of Learning disability (LD), 6 registration, with number of places Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 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 H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over a period of six hours. A full tour of the premises took place and staff and service users were spoken to. Documents and care records were also examined. The inspector would like to thank service users, the manager, deputy, and care staff for their contributions to the inspection. Comment cards, feedback forms and CSCI business cards were left at the home for information and action. What the service does well: What has improved since the last inspection? What they could do better: Documents at the home must be reviewed, amended and updated. The complaint policy must be improved to ensure the process for making a complaint is clear and easily understood. Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 6 The Vulnerable Adult Policy must be updated to reflect the category of professional abuse to ensure staff have up to date information to protect service users from harm or abuse. Recruitment files must have a recent photograph of staff as proof of their identity. 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 H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,5 The homes Statement of Purpose and Service User Guides are good providing service users and prospective service users with the details of the services the home provides enabling an informed choice to be made about admission to the home. The arrangement for assessment is adequate ensuring service users needs are assessed and identified. The arrangements at the home ensure service users needs are met. Contracts are offered by the home to ensure service users tenancy rights are protected. EVIDENCE: The home had a Statement of Purpose and Service User Guide. The Statement of Purpose was well presented, written in plain English and contained useful information about the aims, objectives and philosophy of the home. The inspector noted the document was regularly reviewed however the complaint process needed to be updated. Service User Guides were available and the information it contained was translated using a widget format to make it easy for service users to understand. The inspector noted service user guides were dated and signed by service users and kept in their bedrooms. The home has a Person Centred Planning system to assess the needs of prospective service users and a policy on Care Plan and Review dated August 2005. The staff team have recently completed the Learning Disability Award Framework training and the home has contact with an advocacy service. The inspector noted the home had an Advocates Policy dated August 2005. One service user stated ‘it is so much better than where I was before’. Service users had written contracts that were dated and signed. One contract was signed and dated by the service user Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 9 and the manager and had a review date of August 2006. The inspector noted the home had a policy on Placement Agreement dated December 2003. Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 There is a care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users’ needs. The systems in place at the home support service users to make decisions about their lives. The arrangement for risk assessment is adequate ensuring service users are supported in taking risks in order to maintain an independent lifestyle. EVIDENCE: The home has Person Centred Plans. The inspector sampled the plans and noted they were current and dated June 2005. The plan was drawn up with the involvement of staff, service users, family, friends and advocates and each service user had a named key worker. One service user with specialist communication needs had a communication plan with 1:1 staff support, another service user had an advocate from Kith and Kids based in London and two service users managed their own finances. The home had regular ‘Client Meeting’ and the inspector noted the last meeting was held on the 16th August 2005. The home had a Risk Taking policy that was dated August 2005. The inspector sampled the risk taking plans that were regularly reviewed and updated. One risk plan was dated the 26th July 2005 and signed by the service user, manager and key worker. A service user stated ‘staff give me advice and help to make me independent’. Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 11 Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12,13,14 The arrangements at the home ensure service users have the opportunity to engage in educational activities. Links with the community are good and support and enrich service users social, leisure and educational opportunities. EVIDENCE: The home has a system to support service users in education and occupation. The inspector noted four service users attended Crawley College supported by staff where they were taught living skills, cooking, art, woodwork and motor mechanics. Employability is involved with service users to find them work experience. One service user has a work experience placement with a voluntary organisation helping in the office. The home has links with the community and is close to public amenities. One service user is a member of the church choir and attends church on Sundays. The manager stated the home had good relationships with the local community and service users stated they went to the local pubs, theatre and library. One service user remarked his favourite book is Famous Five. Staff stated service users were supported to participate in leisure activities that included swimming, horse riding, line dancing and weekly trips out. The inspector sampled service user Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 13 activities plan and noted it reflected a range of activities. One service user remarked at weekends he visited his family, went to the theatre or spent time relaxing at the local shopping centre. The home had a coffee evening recently that was attended by service users, relatives, friends and staff. Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 18,19. Personal support was offered in such a way as to maximise service users dignity and independence. The health needs of service users are met with evidence of working with other health care professionals taking place on a regular basis. EVIDENCE: During the inspection it was noted a service user was supported to clean his bedroom by a care staff. The staff used verbal prompts and the service user hovered the carpet in his bedroom and dusted the furniture. The inspector noted service users were smartly dressed in their own clothing. One service user was dressed in a chino trousers and a light shirt and stated he chose his own clothing. Staff addressed service users by their preferred names and the inspector noted service users moved freely in the home. Three service users had 1:1 meetings with the inspector in the privacy of the office. One service user stated the manager is a ‘confidential person and treats people with respect’. The deputy manager stated service users were registered with a local medical practice, a dental practice and chiropody care was provided by East Surrey Hospital. The inspector checked the Health Action Plans and noted service users were registered with a GP based at Homhurst Medical Centre in Redhill. It was recorded in the health action plans one service user had an eye test on the 25th February 2005 and a dental assessment on the 30th March Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 15 2005. The health action plan covered areas of medication, epilepsy, sight, hearing, mental health, feet, nutrition and mobility. Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 22,23. The complaint process in this home is satisfactory with complaints information available to service users, staff and relatives. However, the complaint process must be improved. Arrangements for protecting service users are satisfactory. However, the company’s vulnerable adult policy must be improved to ensure staff have up to date information to protect service users from possible risk of harm or abuse. EVIDENCE: The home had a complaint policy and a whistle blowing policy that was reviewed in August 2005 and kept in the office. The inspector noted the policies were signed and dated by staff and a copy of the complaint policy was in the service user guides. The inspector noted the complaint policy needed updating to reflect a complaint could be made to the commission at any stage as referred to previously in this report and action has been required in respect of this matter. One service remarked he ‘knows how to make a complaint’ and stated he worked closely with the manager to resolve his problems. During a meeting staff stated they were aware of the complaint and whistle blowing procedures. The manager stated the home had a complaint book that was checked and it was noted no complaints were recorded. The home had a copy of the local authority (Surrey County Council) multi-agency procedures on the protection of vulnerable adults dated February 2005. The inspector noted the category of professional abuse was not reflected in the homes policies and action has been required in respect of this matter. The inspector sampled service user accounts and noted they were up to date and correct. Service user monies were kept in individual cash tins that were in a locked cupboard in the office. The home had a policy on Management and Service User Monies and Valuables dated August 2005. Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 17 Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 18 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 standard(s) 24,25,26,27,28,30 The standard of the environment within this home is good offering service users an attractive and homely place to live. EVIDENCE: On the day of the inspection the home was found to be clean, well ventilated and free from mal odour. The standard of décor was good and furnishings and fittings were adequate. Bedrooms were well presented and personalised with family photographs, books, video’s, CD’s, television, CD player, pictures, paintings and ornaments. One service user stated he liked his bedroom because he could ‘customise it’ to suit his own needs, another service user remarked ‘I just like living here’. The inspector noted bedrooms had en-suite facilities. The home had adequate toilets and bathrooms that were clean and hygienic. The communal lounge and conservatory area were spacious and well furnished. The laundry facilities were adequate with two washing machines and a dryer. The inspector noted the home had adequate arrangements for the disposal of waste and a policy on Infection Control dated August 2005. The home provided anti-bacterial hand wash and the inspector noted staff and service users washed their hands regularly. Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 19 Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,36. The arrangement at the home for staffing is satisfactory ensuring there is sufficient numbers of staff to adequately support service users. Recruitment practices at the home are satisfactory ensuring service users are protected from the risk of harm and abuse. However, recruitment files must have a recent photograph of staff. The arrangements for supervision are adequate ensuring staff are well supported to carry out their job. EVIDENCE: On the day of the inspection the home had adequate staffing. On duty were the manager, the deputy and two care staff. The inspector sampled the duty roster and noted it reflected the numbers of staff on duty. The inspector noted the staff team was made up of female members of staff. This was discussed with manager that stated the home had a stable staff team with two vacancies for care staff. The inspector noted the home did not use agency staff and sickness levels were low. The deputy manager stated the home had regular staff meetings. The inspector sampled the minutes of meetings and noted the last meeting was held on 11th August 2005 and attended by eight staff. The home had a Recruitment Policy dated August 2005. The inspector sampled recruitment files that contained the appropriate recruitment papers that included application forms, references and terms and conditions of employment. The inspector noted the files needed up to date staff photographs as proof of identity and action has been required in respect of this matter. The Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 21 home had a Policy on Supervision dated August 2005. The deputy manager stated the home had a supervision structure and staff had been supervised regularly. The manager supervised the deputy and senior care staff and the deputy supervised care staff. The inspector sampled supervision files and noted staff were regularly supervised. One staff was supervised on the 12th July 2005 and the record was signed and dated by the supervisor and supervisee. During a meeting staff stated they were happy with the frequency of supervision and feel well supported by management. Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38 The manager is supported well by senior staff in providing clear leadership throughout the home enabling service users to benefit from a well run home. The arrangements at the home ensure the management of the home is open and transparent. EVIDENCE: The home has an experienced registered manager that has a Social Services Management Certificate and is currently working towards the Registered Managers Award. The manager is aware of her management responsibilities and works in close collaboration with the deputy manager to influence and lead the staff team. The manager described her management style as ‘supportive’ and ‘problem solving’ and stated she had regular supervision and peer group support from attending ‘Managers Meetings’. The manager remarked she introduced the concept of Key Working that has been adopted by homes throughout the company and commented the company had a good support network for staff. During a meeting staff stated the manager shows initiative and spends time ‘building the staff team’. One service user stated the manager is confidential and will deal with any problem. Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 23 Cavendish Care H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 24 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 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x x Standard No 31 32 33 34 35 36 Score x x 3 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cavendish Care Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x x x H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 25 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 YA34 Regulation 19(1)(b) Schedule 2.1 4(1)(c ) Schedule 1(14) Requirement The registered person must ensure that staff who work at the home have a recent photograph in the recruitment file as proof of identity. The registered person must update the Statement of Purpose and the Complaint Policy to reflect that a complaint can be made to the Commission at any stage should a complainant wish to do so. The registered person must ensure the companys policy on the protection of vulnerable adults is updated to include the category of professional abuse. Timescale for action 01.11.05 2. YA1 01.11.05 3. YA23 13(6) 01.11.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA33 Good Practice Recommendations The registered person shall recruit male members of staff to reflect the gender composition of service users at the home. H09 H58 S47704 Cavendish Care V233901 050705 Stage 4.doc Version 1.40 Page 26 Cavendish Care Commission for Social Care Inspection 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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