Inspection on 06/09/06 for Edgecumbe House

This inspection was carried out on 6th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

Edgecumbe House 30/11/05

Edgecumbe House 12/07/05

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 The Crescent Doncaster Road Rotherham Lead Inspector Jayne Barnett-Middleton Key Unannounced Inspection 6 September 2006 12.30 th Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 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.V289277.R01.S.doc Version 5.1 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.V289277.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Edgecumbe House Address The Crescent Doncaster Road Rotherham 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) 01302 813100 Voyage Limited Ian Wainwright Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 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 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. The fees for the care offered at the home at 06/09/06 vary from £1.110 to £3.142. The homes statement of purpose, service user guide and complaints procedure is available in appropriate formats. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted by Jayne Barnett-Middleton. Prior to the inspection contacts made to The Commission For Social Care Inspection, the homes service history and a pre-inspection questionnaire were examined. A fieldwork visit took place from 12.30 pm to 18.15pm. Opportunity was taken to make a tour of the premises, inspect a sample of records including care plans and staff records. Discussions took place with the registered manager, deputy manager, residents and staff. The inspector wishes to thank the manager, staff and residents for their assistance and time throughout the inspection process. What the service does well: What has improved since the last inspection? All previous requirements had been met. Several ceilings within the home had been repaired and redecorated. One vacant bedroom had been redecorated to Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 6 a good standard. The wallpaper on the staircase had been repaired and there were plans to redecorate the area. The laundry days for one service user had been increased which had improved the standard of hygiene and eliminated unpleasant odours. There has been good progress in staff obtaining a National Vocational Qualification and 58 of the staff team hold the award. 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.V289277.R01.S.doc Version 5.1 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.V289277.R01.S.doc Version 5.1 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): 2. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Residents’ needs and aspirations were assessed and their individual needs were reflected in their plan of care. EVIDENCE: Three care plans were checked and these demonstrated that the residents care needs were assessed prior to their admission. This confirmed that the service was appropriate for the resident and provided staff with the information to formulate an individual plan of care. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 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): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Care plans were detailed and described the action that was required by staff to ensure that all aspects of the resident’s personal, social support and healthcare needs were met. Residents were encouraged by the staff team to make choices within their capabilities and were supported to live as independently as possible. All residents had risk assessments, which enabled them to take risks as part of an independent lifestyle. EVIDENCE: Three care plans were checked all of which were detailed and reflected the residents individual care needs. The format gave a good overview of the residents needs and included their preferred daily routines, communication needs and independent living skills. One care plan checked detailed the resident’s needs in terms of anger management. A reactive plan was in place, Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 10 which clearly described the behaviour that the service user would display when anxious, and what action the staff should take to diffuse any potential situation. The care plan did require more detail as to if and when restraint should be used and what action the staff should take. One care file checked was for a service user who had recently been admitted to the home. This was detailed and evidenced that the staff had assessed the residents’ individual needs soon after admission enabling the resident to maintain and develop their independence. The plans had been reviewed on a regular basis with the involvement of the resident which demonstrated that the residents changing needs were reviewed and reflected in their plan of care. Risk assessments had been developed for all residents, which identified the individual risks that were presented to residents on a daily basis and the action required to reduce the risk, enabling residents to live an independent lifestyle. The manager and staff spoke in detail of one resident, who due to recent health problems, was potentially at risk when out of the home. A review of the residents risk assessment had identified that extra planning and staff support was required when the resident chose to visit the community or attend activities outside of the home. The staff said that the extra planning and preparation had proved successful and that the resident was still able to continue with their preferred routine and choice of activities. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 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): 12, 13, 15, 16 and 17. Quality in this outcome area is Good. This judgement has been made from evidence gathered both during and before the visit to the service. Residents had good opportunities to access appropriate activities enabling them to lead fulfilling lives outside as well as within the home. Residents had good access to the community and amenities promoting equality and choice. The daily routines within the home were flexible and promoted independence, individual choice and freedom of movement. Residents were supported and encouraged to take responsibility for some housekeeping tasks promoting their independent living skills. A good choice of food was offered. Residents were supported to eat a healthy diet promoting and maintaining their health and wellbeing. EVIDENCE: The care plans checked included a personal activity plan, which detailed the activities and gave structure as to how the resident, chose to spend their Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 12 week. All residents had good access to activities within the home and the local community which included visiting the gym, swimming and attending day centres. One resident was taking part in the Rotherham show and during the visit was being supported by staff to rehearse for their part in the show. Residents and staff confirmed that there were good activities and educational opportunities available. One resident explained that they worked in a charity shop, which they enjoyed. Two service users said that they had recently started college. The staff said that where possible residents were encouraged to maintain positive relationships with their family and friends. One care plan checked incorporated time for the resident to ring their mother. Some service users visited their families at the weekend. Discussions with staff, residents and observations demonstrated that the routines within the home were flexible and that the residents were supported to maintain and develop independent living skills. Residents did take responsibility for cleaning their bedroom, laundering their clothing and completing some household tasks such as washing the pots and setting tables. A cook was employed and a varied and good choice of menu was offered. Staff and residents said that a good choice of food was offered. The teatime meal looked appetising and well presented. Some bedrooms had kitchenettes, which promoted independent living. One resident said that they sometimes prepared and cooked their own meals. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 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): 18, 19 and 20. Resident’s received personal support, which promoted their privacy, dignity and independence. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place to protect residents from risk. Medication systems in place were good and promoted safe working practices. EVIDENCE: Residents said that their healthcare needs were met and confirmed that the staff encouraged them to take responsibility to make their own healthcare appointments. One resident said that they were due to attend the optician and that the staff were supporting them to book an appointment. One staff member spoke of how they were supporting one resident to take regular exercise by joining them for a walk in the park after tea. Care plans checked and information provided demonstrated that health teams within the community, for example, psychologist and psychotherapists were involved in supporting the staff to meet the resident’s needs. A key worker system was in place, which ensured that residents received consistent support from a designated named worker. One resident spoke Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 14 positively about their designated worker and the support that they had received. There was a medication policy and procedure to ensure that staff adhered to safe practices. The manager said that staff had been trained in administering rectal diazepam for one resident should it be required. Medication was checked on a sample basis. Medication systems were good and procedures were in place to ensure that medication was appropriately administered. Medicines were securely stored and staff responsible for administering medication had received training prior to administering medication independently. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 15 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 and 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The complaints procedure was clear and accessible ensuring that any complaints would be listened to and dealt with appropriately. The homes adult protection procedures promoted the protection of residents from harm or abuse. Some staff was in need of adult protection training. EVIDENCE: The complaints procedure was displayed within the home and ensured that residents and their relatives were aware of how to make a complaint and who would deal with them. No complaints have been made to The Commission For Social Care Inspection. The manager maintained a central record of any informal complaints. Records checked demonstrated that any concerns raised by the residents were dealt with and appropriate action taken to resolve any concerns that they may have. There was an adult protection procedure in place at the home. There was an adult protection procedure in place at the home. Training records demonstrated that some staff was in need of adult protection training to enable them to identify and the procedure to follow should they suspect any abuse at the home. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 16 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): 24 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The home was well maintained, odour free, well decorated and homely, promoting a comfortable and safe environment for residents. The home was clean and the laundry area was appropriately equipped to meet the needs of the residents. EVIDENCE: The environment within the home was clean, comfortable and homely. Residents were observed to move freely around the home and appeared relaxed in their environment. Previous requirements had been met. Several ceilings had been repaired and redecorated. One vacant bedroom had been redecorated to a good standard. The wallpaper on the staircase had been repaired and there were plans to redecorate the area. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 17 Areas seen were clean and odour free. The deputy manager said that the laundry days for one service user had been increased which had improved the standard of hygiene and eliminated unpleasant odours. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 18 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): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The ratio of staff provided was sufficient to ensure that the general and specific needs of the residents are met. A training and induction programme is in place enabling the staff team to meet the general and specific needs of the residents. The home operated a recruitment procedure that promoted the protection of the residents EVIDENCE: Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The Staff were friendly, approachable and relaxed to talk about the care that they provided. Positive and appropriate relationships were observed between staff and residents. Residents spoken to said that the staff team were “supportive” and “helpful”. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 19 Staff rotas demonstrated that the number of staff on duty was sufficient to ensure that the residents received the appropriate support. The deputy manager stated that there was 1 staff vacancy, which had been filled subject to the appropriate checks being carried out. No agency staff was used by the home. The staff confirmed that they would work extra shifts if needed, promoting a consistency of care to residents. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of the residents. Two staff said that they had received the appropriate support during their initial weeks at the home. Both confirmed that an experienced member of staff had supported them until they felt confident to undertake their duties independently. The manager and deputy manager confirmed that training arrangements had been reviewed and that staff had commenced to undertake the required training. Some staff was still in need of Fire and manual handling training. There had been good progress in staff obtaining a National Vocational Qualification in care and 58 of the staff team held the award. A recruitment policy and procedure was in place. Central personnel dealt with recruitment and the manager felt that the systems in place were robust promoting the protection of the residents. Three staff files checked contained a range of information including two references, declaration of health and qualifications/training. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level to promote the protection of residents. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 20 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): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Residents and staff were benefiting from the from the ethos, leadership and management approach of the home. Forums were in place, which encouraged residents to give their views on the care that they received and suggest ideas to develop the service. The health, safety and welfare of residents were on the whole promoted. EVIDENCE: The manager has many years experience with the caring profession and holds a National Vocational Qualification in both management and care. Staff spoken to said that the management team were “supportive” and confirmed that they received one to one support on a regular basis. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 21 Resident meetings were held to enable them to contribute to the day-to-day management of the home. Records checked demonstrated that meetings were held on a regular basis and that residents were given the opportunity to contribute to items such as holidays, meals and activities. The manager said that residents were also encouraged and supported to discuss the care that they received during their one to one sessions with their keyworker. Policies and procedures were in place to promote the health, safety and welfare of staff and residents. Fire records demonstrated that fire checks were being carried out on a weekly basis. However some staff had not received regular fire drills to ensure that they were conversant with the action and procedures to follow in the event of a fire. Systems were in place for the maintenance and servicing of appliances and equipment, which had been checked at the required frequency. Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 22 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 15,13 Timescale for action Care plans must contain detail as 30/11/06 to if and when restraint should be used and what action the staff should take. All staff must receive Adult 31/12/06 Protection training. All staff must receive Fire and 31/12/06 manual handling training. All staff must receive fire drills at 31/10/06 the required frequency. Requirement 2. 3. 4. YA23 YA35 YA42 13,18 13,18 13,23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Edgecumbe House DS0000046545.V289277.R01.S.doc Version 5.1 Page 24 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.V289277.R01.S.doc Version 5.1 Page 25 - 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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