Inspection on 30/01/08 for Cavendish Care

This inspection was carried out on 30th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cavendish Care 19/09/06

Cavendish Care 16/01/06

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 Vera Bulbeck Unannounced Inspection 30th January 2008 10:20a Cavendish Care DS0000047704.V355523.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 Cavendish Care DS0000047704.V355523.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. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 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 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) suekesh@hotmail.com Cavendish care Mrs Sonia Beryl Williams Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2006 Brief Description of the Service: Cavendish Care provides accommodation and care to six client’s with a learning disability. The premises are located in a cliential area, close to public amenities and are in keeping with the local community. Accommodation is provided on three floors accessed by stairs and comprises of a communal lounge, kitchen/dining area, bathrooms, toilets, laundry room, conservatory and six bedrooms with en-suite facilities. The gardens are in the front and back of the property with a private drive for parking. The gardens at the back of the property are attractive, private, secure and accessible by client’s. The scale of charges by the home range from £1300 to £1,600 per week. Items not covered by the fees are toiletries, clothing, hairdressing and some extra activities. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is [3 star]. This means the people who use this service experience [excellent] quality outcomes. This unannounced visit formed part of a ‘key’ inspection and was carried out by Vera Bulbeck, Regulation Inspector. The Registered Manager was present as the representative for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager and any information that CSCI has received about the service since the last inspection. A tour of the premises took place. On the day of this visit the inspector spoke with six clients and four staff on-duty. Prior to the inspection, survey forms were sent to client’s, their relatives and/or advocates and to staff employed at the home, survey forms were also available during the inspection. Five clients, three members of staff and three relatives/advocates, returned survey forms. Some of the comments made to the inspector and made on the survey forms are quoted in this report. One of the client’s is not able to communicate verbally and observations of the interactions between staff and client’s were also used to form the judgements reached in this report. The home had completed an annual quality assurance assessment (AQAA) and client’s’ care plans, staff recruitment and training records, menus, health and safety check lists, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector would like to thank the client’s and staff for their time, assistance and hospitality during this visit and the client’s, relatives and staff who participated in the surveys. What the service does well: Client’s are supported and encouraged to make personal choices and decisions about their own lives, to participate in the day to day running of their home and to expand and develop a social life, both inside and outside their home based on their individual interests and hobbies. Client’s spoken with told the inspector how they were happy living at the home and that they felt safe living there. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 6 The management approach at the home provides an open, positive and inclusive atmosphere for clients and staff. One staff member commented the client’s living in the home have a lot of choice in their daily life. Client’s also commented they enjoy living in the home but some are aiming to move into supported living. One relative commented on a survey the staff are wonderful they try hard to please all the time and they are devoted to the client’s and their work they do. What has improved since the last inspection? What they could do better: The management of the home endeavours to ensure all staff are confident and competent in the use of the computer. This will make updating their client’s care plans, PCP, risk assessments and any other personal data more effective and less time consuming. To use the public transport network more once the new passes have arrived. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 7 The inspector advised the manager to review having covers fitted on the radiators to ensure client’s are safe from any potential burns. Two of the restrictors were broken on bedroom windows and need attention. The pay telephone normally situated in the hallway is broken. A client informed the inspector the telephone has been broken for some time and it was not very good when it was working, as it was not very private to make a call. Anyone now wanting to make a call has to walk into the town centre to make a call. One relative commented about the homes telephone system, and stated the phone was often unavailable, but even worse now with no phone. A relative commented on staff questioning about what had been entered on the survey returned to CSCI at the previous inspection. This was discussed with the manager who stated this was not acceptable and she would deal with it. Another relative commented that it took such a long time, several months for the hot water system to be repaired when it broke down 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. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 8 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.V355523.R01.S.doc Version 5.2 Page 9 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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admission procedures at the home ensure that client’s’ needs and aspirations are fully assessed prior to admission to make sure that their needs can be met. EVIDENCE: The inspector was advised that, on the first enquiry from a prospective client or their representative, the client or their representative would be invited to visit the home for a meal and stay the night. Following the initial visit to the home, and if the client wishes to continue, the manager will visit the client and carry out a pre-admission assessment to ensure that the home can meet the client’s needs and wishes. The manager informed the inspector the client’s in the home have been living in the home for the last four years. Therefore pre-admission assessments had been carried out to ensure that the home could meet the client’s’ identified needs. However there is a new format assessment form, which is held by the general manager and would be used for any potentially new client’s in the future. In the AQAA, the manager stated that we have a client guide and statement of purpose, which includes the range of fees the home charges. These are updated annually and each client has a copy. The service users guide includes Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 10 a list of staff and the qualifications they have. These are produced in plain English and widget form. Each service user guide includes a list of the multi professional team that can be accessed by client’s but this is not exhaustive as each client is an individual and their needs are assessed and addressed as such. The home has a policy for admissions this includes emergency admissions and these were reviewed in July 2007. The majority of client’s surveyed all felt they had received enough information prior to moving to the home, one person said he wished he had more. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 11 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 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The client’s’ individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences. Client’s are supported to take risks as part of an independent lifestyle. EVIDENCE: Prior to this visit, relatives and advocates were sent survey forms, three forms were returned, with two relatives stating that the home always gives the support or care that their relative needs and one answering “sometimes”. Care plans for two clients were sampled and were seen to be comprehensive, well set out and easy to follow. Care plans and person centred plans are drawn up with clients and are reviewed on a three monthly basis, or more often, if needs change or a new concern arises. The staff document daily in a separate sheet for each client to evidence that individual goals and needs are being met. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 12 The care plans were all seen to be very individualised and included the client’s’ personal preferences and also risk assessments for all activities, with clear guidelines for staff to follow to minimise any associated risks. Five completed client survey forms were received prior to this inspection. Five clients stated they are able to do what they want to do during the day, in the evening and at weekends. On the day of this visit, clients were seen to be choosing what they did and where they went within the home. Staff were seen to be helpful and offered assistance where needed or requested. It was also observed that staff had a good rapport with a client who was not able to communicate their wishes verbally, where they indicated that they wanted assistance, this was quickly understood by the staff and the assistance provided. In the AQAA, to demonstrate what the home does well, the manager stated that Individual care plans are in place and are updated continually as and when required, for example doctors visits, assessments and dental or optical checks. There is a formal review of these every 6 months. Client’ are involved in the formation of care plans as are parents if the client wishes them to be. Person centred plans (PCP) are in place and are reviewed formally annually but are all stored on the computer so changes can be easily made as an ongoing process. Staff members involve clients in the updating of the PCP and relatives are involved with the client’s consent. The client’s PCP’s are personalised with their photograph, this has had a very positive response and client’s for their photographs to be used in this way have granted permission. The client’s have a good relationship with their family and are supported by family members. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 13 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): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The client’s have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported to maintain and develop appropriate personal and family relationships. The management of the home ensure that client’s’ rights are respected. Meals are well balanced and varied. EVIDENCE: Client’s confirmed they could choose what to do, when they wanted. This was also confirmed by observations made by the inspector on the day of this visit. Two clients have a part time job and another client is hoping to start work soon, staff are working with the client and have identified a potential, suitable job in the local area that is expected to be available shortly. In the AQAA, to demonstrate what the home does well, the manager states that there is a varied programme of activities during the evenings and all clients have the option to attend these. If a client wants to partake in an Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 14 independent activity within the community this is always considered and supported as appropriate. One client attends a weekly band practise unsupported, one works on a gardening project, one volunteers at a charity shop and another regularly attends the theatre, church and other social activities independent of the other client’s. One of the client’s attends a film club in Brighton and is supported to travel there and back but is unsupported whilst in his club. During the day client’s were going out and returning, one client went to the gym with a member of staff, several client’s attend different colleges for cookery, life skills, computer or art class another client is able to go to the local shops independently, he informed the inspector he has to go into town to use the telephone as the phone in the home is not private and is currently not working. It was obvious during this inspection that the staff team are open and flexible and that no two days were the same. Although each client has an activity schedule, this is treated more as a guide. Clients were seen to be making decisions, at the time, as to whether they wanted to do what was on their schedule or to do something different. Whilst the home has its own vehicles clients also use public transport to prepare them for independently living and offer varied experiences. Two clients attend church on a regular basis and one has good contact with the parishioners and the church is part of his everyday life, and is able to play the organ in church. One client spoke with the inspector about the plans that were being made for his holiday. He has long holidays and his parents who live abroad either collect him or another member of his family will take him to his parent’s home. All the client’s had a holiday last year and will have another holiday this year, which has not been organised as yet. Three client’ went to Butlin’s and one went to America during 2007. Each client had the offer of a week’s holiday during the college break. The venue was decided between the client’s and all enjoyed the trip. The trip was risk assessed before going and any risks that occurred whilst away where addressed on an as required basis. The inspector was informed that client’s choose their own meals and help prepare the meal they have chosen. Members of staff offer support to help client’s expand their choice of menu and thus learn varied cooking skills. Clients have training in food hygiene, manual handling and fire as appropriate to each client. Clients have the option to have a key to their own room but these are often lost and they have all currently declined the offer. The keys are available Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 15 should they request them. They can also take a key to the house when going out but these have also been lost so they are returned to the office upon the client’s return. On the day of the site visit all the client’s had gone out for lunch except one, as new carpets were being laid in the hallway and on the stairs Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 16 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 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen in care notes, to be provided, where needed, in a respectful and sensitive manner. Policies and practices are in place for the administration and management of medication. EVIDENCE: During this visit two care plans were sampled and it was seen that all health care needs were incorporated into the care plans. Records indicated and was evidenced that staff take prompt action to deal with any new health problem that may occur and care plans were specific with information for staff to follow when supporting client’s to manage any long-term conditions. One client is on a one to one and spends time in his bedroom, as he can be quite disruptive to the environment and other client’s living in the home. Some of the client’s informed the inspector he breaks lots of things including the pay phone and sometimes breaks their belongings. The inspector was informed the home has excellent working relationships with the consultant psychiatrist and he is always ready to talk to staff and see client’s if the need arises before their regular review date. There are also strong links between the home and the multi professional team based near by Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 17 and the team are always willing to take telephone queries. New referrals go through smoothly and in a timely fashion. Clients see specialists as and when required including one seeing a neurologist and one seeing a cardiologist. Other health care professionals are accessed through the G.P, consultant psychologist or indirect referrals from other involved professionals. Full assistance is given to clients to access primary and secondary care as deemed necessary by the referrer. If a client is hospitalised full support is given during the day and reviewed at night as required. Each client has a booklet they have completed with their keyworker to help hospital staff support them should the need arise. Medication is provided mostly in the blister pack system. The administration of some medications was observed and the medication administration records (MAR), medication storage, policies and procedures were all sampled and found to be in good order. In the AQAA, to demonstrate what the home does well, the companies medication policy has been updated this year. All staff are working towards a Keele University accredited certificate for carers administering medication. Cavendish’s deputy manager who is a registered nurse and qualified mentor and teacher is mentoring staff. Monthly medication audits are carried out internally and externally by Lloyd’s pharmacy and the results of these have been positive. Any recommendations are immediately actioned within the home. During this inspection, all interactions observed between staff and clients were polite and respectful. Staff never entered client’s private rooms without knocking and awaiting permission to enter. All personal care was carried out behind closed doors. Relatives who returned survey forms all stated that they were always kept up to date with important issues that affected their relative, two answered that they felt the home always met the needs of their relative. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 18 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 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. All required policies and procedures are in place to ensure that client’s feel their views will be listened to. Policies and practices are in place to protect clients from abuse and neglect. EVIDENCE: In the AQAA, to demonstrate what the home does well, the manager stated that the home has a complaint’s procedure in place that is available to all client’s, has been individualised to the home and is available in an easy read, picture format if required. The company’s complaints policy was updated July 2007. In house have a complaints book for client’s, which they can all access. In the client guide there is a detailed description of who CSCI are and how to contact them if the client wishes too. There has been one complaint made in November 2007, which was referred to the safe guarding team. A copy of the complaints procedure is displayed in the hallway. All clients have been provided with a copy detailed in the service user guide. Copies are kept in each individual’s bedroom. The management of the home has introduced a grumbles book for the client’s who wish to make their concerns known without making a formal complaint. The manager stated staff has been instructed to take all client complaints seriously and deal with them as and when the complaint arises. No complainant has contacted the Commission with information regarding a complaint or allegation made to the service since the last inspection. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 19 All staff are up to date on their vulnerable adult training and there is a company policy on safeguarding vulnerable adults. There is a copy of Surrey County Councils procedure for the protection of vulnerable adults available and staff are aware of this document. There is a company policy regarding whistle blowing and any concerns are immediately addressed. Client’s surveyed all stated that they knew who to talk to if they were not happy. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 20 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and generally well maintained. The home was found to be clean and hygienic and to meet client’s’ individual and collective needs in a comfortable and homely way. EVIDENCE: Client’s spoken with expressed their satisfaction with the accommodation provided at the home. Two of the client’s surveyed said that the home was always fresh and clean. The home was toured during this visit. The furniture and furnishings were seen to be of a good quality and specialist equipment is provided if needed to the client’s. Client’s bedrooms were personalised to the individual wishes. On the day of the site visit new carpets were being laid in the hallway and on the stairs. There were a few areas in the home that require attention. For example, in one bedroom a chest of drawers was broken the manager stated that a new Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 21 chest of drawers was on order. A client’s bedroom door (fire door) had a gap, which one could see day light through the inspector advised the manager to ensure the door is attended to without delay, as this could be a potential hazard. In another client’s bedroom there were no curtains at the window the inspector was informed that the client pulls them down. The inspector advised the manager to look into the possibility of a blind on the outside so that the client has privacy and respectful of his dignity. In the same bedroom it was established that there was no soap, towels or toilet roll, the inspector was informed that staff are not able to leave these items in the bedroom for the client’s own safety. Once again this practice needs to be reviewed and another alternative to be explored. One client has his bed beside the radiator, which is very hot. The manager stated all the client’s have been risk assessed. The inspector advised the manager to review having covers fitted on the radiators to ensure client’s are safe from any potential burns. Two of the restrictors were broken on bedroom windows and need attention. Laundry facilities are sited on the ground floor with washing machines suitable for the needs of the client’s at the home. In the laundry room it was noted that vanish cleaning agent was in one of the unlocked cupboards. The manager removed the tub and stated that client’s are not using the laundry without staff support. However, all cleaning materials must be stored in a locked facility to ensure the health and safety of all clients living in the home. The outside wall in another client’s en-suite needs attention. There is a private and well-maintained garden at the back of the house. Where another client named Bubbles the rabbit lives in his hutch and belongs to one of the client’s. The client’s and staff work together in maintaining the garden. On the day of the site visit the home was found to be warm and bright with a homely atmosphere. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 22 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. Competent and qualified staff supports Service users. An effective staff team supports Service users. Service users are supported and protected by the home’s recruitment policy and practices. Appropriately trained staff meets Service users’ individual and joint needs. 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): 32, 34 and 35. 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 staff training and recruitment programme which is designed to ensure that client’s are supported by competent and qualified staff, as far as reasonably possible, they are protected from harm. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the client’s at the home. There are two care staff on duty between (8am – 10pm) and the manager. One person sleeps in the lounge on a pull out sofa and another member of staff is on call and available if needed. During this visit the file of one recently recruited member of staff was sampled and one other member of staff. All files were seen to contain proof of identity, two references, a completed application form and enhanced Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) list checks had been obtained. The home was also able to verify applicants’ reasons for leaving previous employment with vulnerable adults; ensure they obtain a full employment history and a written explanation of any gaps in employment. All staff surveyed confirmed they had been supplied with a copy of the General Social Care Council (GSCC) code of conduct and practice. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 23 Staff induction is in line with the new, mandatory Skills for Care common induction standards and the inspector was advised that staff are supervised until they have completed their induction. Staff are booked on additional training and updates as the courses become available. As stated in the AQAA, to demonstrate what the home does well, the manager confirmed that all staff has LDAF and four staff has completed NVQ Level 2 and above, another member of staff is in the process of completing NVQ training in 2008. The deputy manager has a BSC honours degree in nursing. All mandatory training is up to date. All staff files are up to date and stored in a locked cabernet to maintain confidentiality. All staff receive induction and once the staff member and supervisor are happy and completed it is signed by both. Other formal training is available and staff are offered a variety of courses pertinent to their work. They are always encouraged to request courses that they feel are pertinent and then these are looked at and a decision made. One member of staff commented that she was ‘very happy with the level of training’ provided by the home. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 24 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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Client’s benefit from the management approach at the home providing an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the client’s. Policies and procedures are in place to ensure, so far as is reasonably practicable, the health, safety and welfare of client’s and staff. EVIDENCE: The registered manager informed the inspector that she would be retiring at the end of March 2008. She is supportive of her team and has an open door policy, which allows client’s access to management at all times. As stated in the AQAA, to demonstrate what the home does well, the manager stated the home has a quality assurance policy and questionnaires are used to ask parents, client’s, relatives, neighbours GPs and other professional agencies for their views. The organisation carry out a yearly survey, which Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 25 seeks the views of client’s, family, friends and other stakeholders in the community (i.e. district nurses etc.) Regulation 26 visits are carried out with actions taken as required, these reports need to be expanded to cover more detail. Client’s’ views are sought on a regular basis. The AQAA states health and safety tests are up to date including portable appliance testing, gas, water temperature and electrical testing. Fridge and freezer temperatures are checked daily. Meat temperatures are also recorded as and when appropriate. Water is checked for legionaries’ disease twelve monthly and decaling takes place on a weekly basis. It was noted at the time of the inspection that the testing of the fire alarm system needs to be undertaken on a regular basis. The records sampled indicated the last test was dated 14/01/08, and previous tests were recorded as 06/01/08, 03/12/07 and 20/11/07 the alarm system needs to be checked and tested weekly. There was a fire risk assessment in place however, this was discussed with the manager and the inspector advised the manager to contact the fire officer for advice regarding the fire risk assessment needs to cover the whole house. The management needs to implement an emergency contingency plan. The Fire safety officer has informed the inspector that an emergency contingency plan has already been implemented since the inspection. The inspector also advised the management to contact the Environmental Health Officer, as the last visit was dated 03/09/07 and it would appear that there could be some misunderstanding regarding the food being cooked in the kitchen with regards to staff supporting client’s to cook food. Relatives who returned comment cards stated that they were always kept up to date with important issues affecting their relatives and that they felt the home meets the different needs of the client’s. One relative commented: ‘the manager and staff are devoted to their work. Another relative commented: “There is a warm friendly atmosphere the staff are wonderful they try hard all the time to please absolutely delighted with the home and the devoted staff”. Another comment was the pay telephone is often unavailable and not working. The telephone was not working on the day of the site visit. A client informed the inspector he often has to walk into the town to make a phone call. He also stated when the phone is working it is not private and is placed in a public area. Of the six client’s spoken to confirmed the staff always listen and act on what they said. Additional comments made included: ‘I am very well looked after’ and ‘the staff are very helpful and friendly.’ One client commented that he is working towards independent living. Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 26 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 3 X X 3 X Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 27 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 YA24 Regulation 23 Requirement Several areas need attention in the home: • Broken chest of drawers • Two broken window catches • Wall needs attention in a client’s en-suite • Client’s bedroom door not fitting appropriately • Ceilings need attention following leaks. To provide a telephone for client’s to use. Timescale for action 14/03/08 2. YA39 16 14/03/08 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 2 3 4 5 6 Refer to Standard YA24 YA24 YA24 YA39 YA42 YA42 Good Practice Recommendations Maintenance book need to be kept up to date. Covers for radiators to be reviewed To consider an outside blind for a client’s bedroom. Regulation 26 visits to be expanded. To contact the Environmental Health Officer for advice. Fire alarm system to be checked on a weekly basis. DS0000047704.V355523.R01.S.doc Version 5.2 Page 28 Cavendish Care Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Cavendish Care DS0000047704.V355523.R01.S.doc Version 5.2 Page 29 - 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!