Inspection on 24/06/05 for Cavendish House

This inspection was carried out on 24th June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cavendish House 08/05/07

Cavendish House 01/11/04

Cavendish House 17/05/04

Similar services:

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Southfields

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33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Cavendish House 4 Saxbys Lane Lingfield Surrey RH7 6DN Lead Inspector Mrs M McHugh Announced 24 June 2005 10:00 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 House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cavenish House Address 4 Saxbys Lane, Lingfield, Surrey, RH7 6DN 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) 01342 833297 Monica Cantwell Trust 48 Saxbys Lane, Lingfield, Surrey, RH7 6DN Mr Gerald Michael Loney Care home only (PC) 5 Category(ies) of Learning disability (LD), 5 registration, with number of places Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The age/age range of the persons to be accommodated will be: 18-65 YEARS Date of last inspection 01 November 2004 Brief Description of the Service: Cavendish House is a large terraced house situated in the village of Lingfield approximately eight miles from Horley in Surrey. It provides care for up to five younger adults with a learning disability. All bedrooms are single and most are found on the first floor which is accessed by a flight of stairs. One bedroom is located on the ground floor. The home provides communal areas with two lounges, a dining room and a family style kitchen. There is a good size garden to the rear of the property, that is fenced and secure. There is only on-road parking availble in front of the house. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over five hours. A tour of the premises was undertaken and staff and resident’s records were sampled during the day. Four of the five residents were spoken with during the inspection and the inspector received comment cards back from all of the residents. Letters were received from relatives of two residents in the home. What the service does well: What has improved since the last inspection? What they could do better: The registered person needs to ensure that staff files have all the information as required by legislation, including proof of identity and two written references. The home must ensure that any COSHH (Control of Substances Hazardous to Health) items are locked away or if used by the residents for cleaning, these items should be risk assessed in order to promote the protection of the residents. This will promote the safety and welfare of residents and ensure the compliance with health and safety legislation. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 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 House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 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 House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 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 and 4 Residents have the information they need to make an informed choice about where to live. The home has an appropriate admission procedure in place that includes a needs assessment of an individual and offers the person an opportunity to visit the home on several occasions. EVIDENCE: The home has a statement of purpose and a resident’s guide that informs the resident and their relatives about the home, what costs are included and extra from the fees, what activities the home is able to provide, staffing levels and more. Some residents had an interest in these documents. All residents are assessed prior to admission to the home and information is gained from as many sources as possible including care manager, previous placement, relatives and any activity centres the resident was involved in. Prospective residents are invited to visit the home prior to moving in the see if they like it and if the current resident group and the new person are compatible. The manager stated that they would not accept anyone into the home if the current resident group were not happy or did not feel comfortable with the prospective new resident. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 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 standard(s) 6, 7, 8, 9 and 10 The systems for service user consultation were good, with a variety of evidence that indicated that resident’s views are sought in relation to their needs and aspects of their lives in the home. There was clear care planning and risk assessing systems in place. Residents are aware that any information about them is handled appropriately. EVIDENCE: Resident’s files sampled showed a care plan was in place and these included all aspects of care, including physical, emotional, social, health, daily routine and communication. The risk assessment formed part of the care plan, where risks were identified and plans were in place on how to minimise these risks. Most of the residents were aware of what puts them at risk and why staff sometimes need to intervene to keep them safe. Residents informed the inspector that they have weekly meetings on a Friday where they discuss the menu for the following week, allocate chores for the day and generally discuss any issues that have come up during the week. Minutes of these meetings were seen. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 10 All records are held in the office and confidential information is locked away in filing cabinets. It was discussed with the manager that it may be advisable to lock the office when staff are not around and at night time. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17 Links with the local community are good and through this the residents are well supported in social and educational aspects. The menus are chosen by the residents and offer variety and take into account any preferences or dietary needs. EVIDENCE: The residents have an active calendar for most days of the week. They attend college, go to a day centre, assist in the local charity shop, assist with the meals on wheels programme in the community, attend various clubs and go to church on a Sunday. Leisure activities include swimming, going to the cinema, meals out and country walks. Residents stated that they like to be active and attend lots of social events. Many residents told the inspector about their favourite activity and that they had plenty of leisure time too. The manager stated that the residents are well known in the community and this gives them a feeling of belonging. This was echoed in a letter received from one of the resident’s relatives. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 12 Most of the residents have good family support and input and the staff work hard to encourage as much family involvement as possible. Relatives stated that they are kept up to date with what their relative is doing and when they are going away with the house. Meals are provided by staff with residents assistance. The residents choose the menus for the week and are involved in the shopping for the house. Some residents stated they prefer to wash up and lay the table and others prefer to help with the cooking. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 The staff have a good understanding of the residents support needs and have good interpersonal relationships with the residents. The health needs were being met with evidence of consultation with other professionals. EVIDENCE: Residents stated that staff help them when needed, whether it is deciding on clothing to wear or with personal care. Residents are assisted when they are in the bathroom although the amount of support needed varies from resident to resident. Staff stated and this was backed up in the individual residents records that residents visit the GP when required and that other health needs are met. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Complaints are responded to appropriately and staff are aware of that residents must be protected from abuse, neglect and self-harm. EVIDENCE: The home has not received any complaints in the last year. Residents stated that if they were unhappy or had a complaint they knew who the could talk to and that they would not have any trouble saying if something was wrong. All the residents were very vocal about what they liked in the home and how they would talk to their key worker if something were wrong. The manager stated that all relatives are aware of how to complain. The home has a protection from abuse procedure in place and a copy of the local authority Multi-agency procedures. Staff were aware of the types of abuse and residents stated that staff never treat them badly or shout at them. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30. The general standard of the environment within this home is good, providing residents with an attractive, clean and homely place to live. EVIDENCE: Residents stated that they like their home, which is homely, comfortable and provided a safe environment. Resident’s bedrooms were individually decorated and reflected the individual person’s tastes and needs. The home provides three bathrooms with a bath and/or shower available. Communal areas were spacious and provided a choice of space. The home also has a nice sized garden that provides extra space in summer time. None of the residents require specialist equipment at this point, however the manager showed an awareness of where to obtain any equipment that was required. On the day of the inspection, the residents were involved in their weekly cleaning chores with supervision from staff. The home was clean and tidy. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 The staff team in place offer consistency of care and support to residents within the home. Staff are clear about their roles and training is in place. There was a need for improvement in respect of recruitment practices. EVIDENCE: The staff team are aware of their duties in the home and were observed to work well together during the day. Residents stated that the staff are nice and help them when they need help. They also stated that they would talk to staff if they had a problem and that staff are kind to them. Three staff are now on the NVQ level 2 training and all staff have received induction and foundation training relevant to the work they do. The manager informed the inspector of a number of training courses staff have attended or are due to attend. The staff files sampled did not contain all of the information required by legislation and this must be rectified. Staff records must contain proof of identity and two written references. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 39, 41, 42, 43 Residents benefit from the ethos, leadership and management approach which leads to a well run home. Residents’ views are important to the home and best interests are safeguarded by the home’s record keeping. Residents’ health, safety and welfare is promoted. EVIDENCE: The manager was observed to interact well with the residents and maintains respect at the same time. The home is run in line with a family home and residents views are sort in all aspects of how the home is run and managed. Residents stated that staff ask them what they should do in this or that situation and encourage residents to take responsibility for their actions. The record keeping was satisfactory and the recording process ensured the safety of residents and staff. Residents health and welfare was paramount to the home and any risk assessments were in place to help protect residents for injury. It was noted during the visit that there were some hazardous items left Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 18 in the upstairs bathroom. While it is acknowledged that the residents were cleaning areas of the house, these items were still in the bathroom at the end of the inspection. The home should risk assess these items against the safety and welfare of all the residents in the home or must be locked away in a cupboard. Financial records for the home were viewed and were satisfactory. The inspector sampled resident’s petty cash booklets and good records were maintained. Two residents look after their own finances without staff input. Cavendish House H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 19 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 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 4 4 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cavendish House Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 3 3 3 H09 H58 S13585 Cavendish V225563 240605 Stage 4.doc Version 1.30 Page 20 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 YA 34 Regulation 19(4)(b)i) Schedule 2 Requirement Staff files must contain all the information as required by legislation. Timescale for action 24/07/05 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. 2. Refer to Standard YA 10 YA 42 Good Practice Recommendations The office should be kept locked when no staff are around and at night time. Hazardous items, including cleaning items, should be locked away or risk assesssed for each resident. 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