Inspection on 12/07/05 for Edgecumbe House

This inspection was carried out on 12th July 2005.

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 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

Edgecumbe House 06/09/06

Edgecumbe House 30/11/05

Edgecumbe House 24/11/04

Edgecumbe House 19/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 EDGECUMBE HOUSE Edgecumbe House The Crescent Doncaster Road Rotherham Lead Inspector Alan Bartrop Unannounced 12 July 2005 09:00 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. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Edgecumbe house Address Edgecumbe House, The Crescent, Doncaster Road, Rotherham 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) 01302 813100 Voyage Limited Ian Wainwright Care Home 10 Category(ies) of Learning disability (10) registration, with number of places EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager attains the required level 4 NVQ (or its equivalent) management qualification by 2005 2. The basement staircase must not be used by residents. Date of last inspection 24-Nov-2004 Brief Description of the Service: Edgecumbe House is a care home for adults with learning disabilities, which is situated near the centre of Rotherham. The home is a converted building that consists of 2 floors for the use of the service users, and a cellar that is used as office accommodation only. There is a second cellar that is not suitable for use either as office accommodation or for any use by service users. The home is situated in it’s own grounds which are securely fenced off. Rotherham town centre is a ten-minute walk away and there is a large municipal park situated within a three minute walking distance. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home conducted whilst the manager was present. It started at 09:00 and concluded at 15:30. The inspection involved discussions with residents and staff, a tour of the building, and inspection of case files and other records. Lunch was taken with the residents and staff. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 6 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 EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 7 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) 2 Each service user has a care plan which identifies their individual needs and support requirements to enable them to live a full life within the community. EVIDENCE: Care plans were inspected that contained enough detail for the carers to deliver individualised care and records of the care provided indicated that this was delivered appropriately. Observation of the care staff interacting with the residents showed that there was a good rapport between the two groups, and a friendly atmosphere was maintained. Restrictions on the freedom of the service users was recorded and there was evidence that this was relaxed as the service user developed their own ways of dealing with situations that they found themselves in. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 8 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 The service users are asked about different aspects of their lives and are involved in the planning of their daily routines. The care plans are reviewed on a regular basis and generally updated as new needs are identified. EVIDENCE: Service users said that they were asked to make decisions and this was confirmed by observation. There was a good rapport between the service users and the staff where service users were seen to be approaching staff to offer their views which are then taken into account. Evidence was seen that where there is a restriction to a person’s freedom this is recorded in the case file and the placing Authority in involved in the decision and made aware of the reasons so that agreement is reached by all parties. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 9 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) 12,13,16 There is a range of activities offered to the service users, many are done on a 1:1 basis both within the home and in the community. Wherever possible the facilities in the community are used in preference to specialist facilities. EVIDENCE: Activities are recorded as part of the individual’s care and there are records indicating the activities that have been carried out. There are records indicating that the residents have used the local facilities either with staff help or by themselves. Independent development is recorded as part of the care planning and there was evidence that the plans had been changed to take into account the new levels of independence achieved. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 10 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) 18,20 The service users are approached differently dependent on their needs and desires, so that they feel happy and relaxed with their carers. The way medication is received, stored, and administered, has greatly improved since the last inspection. EVIDENCE: Observation of the interaction between service users and staff showed that both parties were comfortable with each other. The medication was thoroughly checked and all aspects of this process were of a very good standard. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 11 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) 23 There is a philosophy within the home of allowing the service users to express their views and become involved in the planning of their days activity. EVIDENCE: Service users were regularly asked for their opinions and when these were offered the staff made time to listen to them and respond in an appropriate manner. Residents were able to confirm that they were regularly asked what they wanted to do and they felt able to approach the staff with ideas that would be listened to. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 12 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 The home is well maintained and kept clean giving a homely appearance and freedom for the service users to use the different areas to carry out different activities. Where service users are given responsibility for cleaning their own bedrooms or other areas of the home the staff must still monitor these areas to ensure that they are maintained to an adequate standard. EVIDENCE: There is a cleaning rota that is adhered to. Where service users were given responsibility for maintaining the cleanliness and tidiness of their bedrooms there was no evidence found to prove that the standard required had been discussed and agreed. This meant that the service users was somewhat in the dark as to whether or not they were meeting the required standard. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 13 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) 36 The staff receive regular supervision which is recorded and there is a training plan to ensure that the staff are provided with the knowledge that they need to do the job effectively and to follow the procedures as required by the company. EVIDENCE: Supervision records were examined and these showed a good range of subjects covered and details of discussions held that indicated there is a good range of experience among the staff group. Training records prove that there is a good range of training courses offered covering a wide range of subjects. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 14 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) 42 There are good procedures in place to promote the health and safety of the service users whilst in the care of the organisation. EVIDENCE: The training plan covers aspects of health and safety and there is evidence that the staff have attended these courses. Observation of the staff at work confirmed that good techniques were used for moving and handling items and that the service users were advised on how to protect their backs from injury whilst picking things up. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 15 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 x Standard No 31 32 33 34 35 36 Score x x x x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 EDGECUMBE HOUSE Score 3 x 4 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 16 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 6 Regulation 15 Requirement Where inapropriate sexual behaviour is identified there must be a plan put in place to address the issue in a consistant manner as soon as it is discovered Timescale for action 25th August 2005 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 20 24 Good Practice Recommendations The decision to retain rectal diazepam home be reviewed along with how up to date the skills of the staff are to administer the drug. When shower mats become very discoloured they are replaced. EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 17 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI EDGECUMBE HOUSE 20050912 Edgecumbe House X00023 UN Stage 4 S46545 V174731 J55.doc Version 1.30 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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