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Inspection on 30/11/05 for Edgecumbe House

Also see our care home review for Edgecumbe House for more information

This inspection was carried out on 30th November 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service offers an environment where service users can develop a life style where they are an integral part of the community using the services and amenities around Rotherham, as well as those farther a field owned by the company. There is an emphasis on the service users making their own choices and implementing their own plans.

What has improved since the last inspection?

The handling of the medication continues to improve as do the care plans for the service users. The staff were seen to be reacting appropriately when service users made inappropriate physical contact with them.

What the care home could do better:

Before staff are expected to administer medications such as Rectal Diazepam they should be authorised to do so by a responsible person. There should also be a requirement for refresher training at prescribed intervals and dependent on the frequency of administration since the last training. The building is showing signs of wear and a more pro-active maintenance regime would minimise the effect of this. Some of the areas of the home had unpleasant odours which should be eliminated quickly.

CARE HOME ADULTS 18-65 Edgecumbe House Edgecumbe House The Crescent Doncaster Road Rotherham Lead Inspector Alan Bartrop Unannounced Inspection 30th November 2005 10:00 Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Edgecumbe House Address Edgecumbe House The Crescent Doncaster Road Rotherham 01302 813100 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) Voyage Limited Ian Wainwright Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The registered manager attains the required level 4 NVQ (or its equivalent) management qualification by 2005 The basement staircase must not be used by residents. Date of last inspection 12th July 2005 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 DS0000046545.V266691.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that involved talking with and observations of service users, a tour of the building, reading records, talking with staff and the manager, inspection of care files. The inspection started at 10:00 and ended at 15:30 What the service does well: What has improved since the last inspection? The handling of the medication continues to improve as do the care plans for the service users. The staff were seen to be reacting appropriately when service users made inappropriate physical contact with them. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 6 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 DS0000046545.V266691.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 The service users have a written contract and statement of terms and conditions with the home. EVIDENCE: Contracts are available for all the service users and these are kept in the home and available for inspection. None of the service users are self-funding, and all the contracts involve Social Services Departments. The placement is reviewed on a regular basis during meetings between the home’s staff and the representatives of the placing authority. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 The residents are involved in decision making as much as possible. The service users are monitored to ensure that the risks they take are appropriate and allow them to maximise their lives whilst receiving a good level of support to minimise dangers. EVIDENCE: Care files have risk assessments documented and reviewed on a regular basis. Service users are encouraged to go out and take controlled risks in order that they can experience a wide range of situations with appropriate support. Community facilities are used whenever possible for educational, social and work related activities. There is a range of activities organised within the home to meet the needs of the service users who do not regularly go out. Residents are always consulted before they take part in any activities. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 10 There was evidence that preparation was made, for situations that were anticipated for the near future, to support service users during a potentially difficult period. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 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 the following standard(s): 15,17 Relationships within the home are appropriate to meet the needs of the service users. Wherever possible good relationships are maintained between the residents and their families. There is a good range of food offered at meal times and the residents are always given a choice of what and where to eat. EVIDENCE: The visitor’s book had details of visits to the home by families and friends of service users. Residents were looking forward to going home with their families and one resident was picked up by his father at the start of the inspection. The lunch was conducted in a friendly manner where the residents did not have to rushed their meals. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 12 Residents were asked what they wanted for lunch and their choices offered to the different people was appropriate. The meals offered are varied and indicated that a balanced diet was provided with weight maintenance issues taken into account. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 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 the following standard(s): 19,20 There is good provision for meeting the emotional and physical needs of the service users. Medication storage and administration remains good and there has recently been training on administration of specific medications. EVIDENCE: Records show that there is a good relationship maintained between the home and the general practitioners who look after the service users. The relationship between the home and the hospital consultants regarding the needs of specific residents is good and the links between these services are strong. The care plans include assessed needs that the residents have about their emotional and physical needs and how these are to be met. Observation of the care staff indicates that a consistent approach is taken between the different staff groups to ensure that the responses to the residents do not differ dependent on the staff on duty. There is still a concern about the effectiveness of the staff administering Rectal Diazepam. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 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 the following standard(s): 22 The service users do have their views listened to and the staff respond appropriately to the requests of the service users. EVIDENCE: A service user stated that if they made a complaint the staff put it right and told them what had been done. There were good examples noted where the staff put a lot of effort into enabling the service user to make a choice of what to eat for lunch. Residents said that they were helped to decide what they would like to do and that they were helped by staff to do the things that they chose. The service users could make complaints and the complaints procedure is displayed on the notice board in the dining room. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 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 the following standard(s): 30 The home was generally clean and well maintained but there were some areas that could be improved. EVIDENCE: The home is cleaned on a regular basis and there are rotas to ensure that all areas receive an appropriate level of attention. Some of the bedrooms continued to have an unpleasant smell until well after lunch. One area was noted where there had been a water leak and the ceiling still had not been repaired. Service users are encouraged to keep their own bedrooms clean with the help of staff and they also get involved in laying tables for meals. When activities such as art have finished the residents said that they also helped to clear the equipment away. The grounds are maintained in good order and accessible to all the residents of the home. There is one spare bedroom that will need decorating before a new resident moves in. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 The staff received training from outside agencies, this has now changed to put a greater emphasis on ‘in house’ services but these have been delayed due to the incapacity of the person employed to deliver the service. EVIDENCE: The home does not have 50 of the care staff trained to National Vocational Qualification level 2. There is a training plan which identifies the training that each member of staff has had and any needs they have for future courses. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 The service users are asked what they want to do and their families are included in the care planning process. EVIDENCE: Service users were asked what they wanted to do during the day. Residents confirmed that they were included in the decision about their daily routines. Care files included activities that had been planned but the resident had chosen to change the itinerary. The policies and procedures of the company state that the service users views must be taken into account as part of the decision process. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 18 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 X X X 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Edgecumbe House Score X 3 3 x Standard No 37 38 39 40 41 42 43 Score X X 3 X X X x DS0000046545.V266691.R01.S.doc Version 5.0 Page 19 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 YA20 Regulation 20 Requirement Timescale for action 01/02/06 2 3 4 YA30 YA30 YA35 23 23 18 Staff who are expected to administer Rectal Diazepam are Authorised to do so by a responsible person Bedroom Ceiling identified during 01/03/06 the inspection be repaired and redecorated Unpleasant odours be kept away 01/02/06 from the bedrooms 50 of Care Staff be trained to 01/04/06 National Vocational Qualification level 2 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 Refer to Standard YA24 YA24 YA30 Good Practice Recommendations Wallpaper is re-fixed to the walls on the stairwells. Damage to the walls and decoration is repaired. Regular, recorded, monitoring of the cleanliness of the home is done. Edgecumbe House DS0000046545.V266691.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr 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 DS0000046545.V266691.R01.S.doc Version 5.0 Page 21 - 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. 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