Inspection on 28/04/06 for 4 - 6 Cavendish Road

This inspection was carried out on 28th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 - 6 Cavendish Road 12/05/09

4 - 6 Cavendish Road 29/04/08

4 - 6 Cavendish Road 24/05/07

4 - 6 Cavendish Road 09/01/06

4 - 6 Cavendish Road 11/10/05

4 - 6 Cavendish Road 10/03/05

4 - 6 Cavendish Road 22/11/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 4 - 6 Cavendish Road Felixstowe Suffolk IP11 2AX Lead Inspector Mary Jeffries Unannounced Inspection 28th April 2006 11:30 4 - 6 Cavendish Road DS0000048200.V291721.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 4 - 6 Cavendish Road DS0000048200.V291721.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. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 4 - 6 Cavendish Road Address Felixstowe Suffolk IP11 2AX 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) 01394 286990 Together: Working for Wellbeing Mrs Janet Gentry Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (13) 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be under 65 years of age at the time of admittance to the home. 9th January 2006 Date of last inspection Brief Description of the Service: The home is situated in a residential area of Felixstowe within easy reach of the beach and local amenities, such as shops. The home is in two linked adapted domestic houses, providing accommodation on three floors. Cavendish Road has a small back garden, which is accessible to residents and is attractively designed. The home is registered for thirteen residents with mental disorder. Residents are aged below 65 years of age at the time of admission, but may remain at the home over 65 years of age, so long as the home is still able to meet the resident’s physical and mental health needs. The home is owned by Together: Working for Wellbeing, which was previously known as MACA. The home’s manager is Janet Gentry. The current charge for residents is £649.14 per week. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection, which focused on the core standards relating to younger adults. The report has been written using accumulated evidence gathered prior to and during the inspection. The inspection started just before midday and lasted all afternoon, it took approximately six hours. There were eleven residents living at the home at the time of the inspection, and two vacancies. One of the eleven residents was in hospital. A senior carer facilitated the inspection until three o’clock, the Registered Manager attended for the final part of the inspection, having been out on appointment earlier on. Two other members of care staff were spoken with in some depth. A resident accompanied the Inspector on a tour of the building. Three other residents were tracked, although one did not wish to talk to the Inspector. Three residents, including one of those tracked were spoken with in a group. What the service does well: What has improved since the last inspection? What they could do better: The security of the building was not maintained, and must be. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 6 The home’s paper work for residents’ care plans and on going recording needs to improve, and to support active involvement in developing the quality of life of all residents. The method of providing medication to residents whilst they are away from the home must be improved, and self-medicating residents must be risk assessed. Bars of soap must not be left in communal bathrooms. Records of Criminal Records Bureau checks having been undertaken must be retained. The home must consult with the fire authority in respect of a fire door on the stairwell, where a change in the position of the handle had compromised its width, and must have a fire risk assessment available. Regular supervision must be undertaken and recorded. Monthly regulation 26 visits must be maintained. The home’s Certificate of Registration must be on display. 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. 4 - 6 Cavendish Road DS0000048200.V291721.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 4 - 6 Cavendish Road DS0000048200.V291721.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): 2,5 Prospective residents can be confident that their individual needs will be assessed. EVIDENCE: At the last inspection a requirement was made that the home must make sure it does not admit any resident that is on a mental health section other than the section 117. The manager’s written response to this was that the admission process is such that a thorough risk assessment, care plan and full information must be available to the home before a decision is made. The most recently admitted resident had a full Care Programme Approach assessment and care plan, dated prior to admission, on file. One resident explained, “ I came just over a year ago. I had a meeting with the deputy manager, staff and residents. They said I had the place. You have a trial for a month”. Staff advised that one resident’s trial period had been extended, by agreement at the outset. This resident was in hospital for a medication review at the time of the inspection. The home’s QA reports which focus on a different area of the standards each month have indicated that a resident will be asked to show round a prospective resident, and that their views will be listened to. One of the residents spoken to in a group advised, “we are not asked if they fit in.” All three of the residents tracked had contracts and licence agreements on file. 4 - 6 Cavendish Road DS0000048200.V291721.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): 6,7,8,9,10 Whilst residents can expect to have regular Care Programme Approach reviews, they cannot be assured that the home’s care plans, which focus on daily living within this overall approach, will reflect any changes made in these. Residents can expect to be consulted on and participate in most aspects of life in the home and that information about them is handled appropriately. EVIDENCE: Staff advised that they did not have any residents in the home who were subject to Section Three of the Mental Health Act. All the residents living in the home are part of the Care Programme Approach process and have regular formal reviews every six months; this was witnessed in the care plans of two of the three residents tracked. The third had not been in the home for six months. In addition to this, carers and residents advised that they have allocated key workers who focus on individual residents’ changing needs. A senior spoken with had a very good knowledge of the needs of the residents that they key worked. The manager advised that they have 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 10 been able to develop and build up the relationship with the local community mental health team, which assists in finding alternative placements if the home is no longer able to meet a residents needs. The home’s visitors book showed good contact with professionals visiting from this service. The three residents spoken in a group were all aware that they had care plans, although one said that they didn’t really understand it. The residents described how reviews involved their key worker and a Community Psychiatric nurse (CPN). Care plans were kept in a filing cabinet the office, and the office was locked when no one was in it. A separate folder of risk assessments was maintained, and the main plan indicated the risk assessments that were present. Two of the three residents tracked and who were willing to speak were fully aware of their care plans and their goals. One showed the inspector a copy of their last Care Programme Approach review in their bedroom drawer, but this was dated September 2005. Various elements of the care plan were dated as reviewed on 17/11/05, and a note in this residents file dated 17/11/05 stated awaiting new plan from CMHT. This was not on file. The homes care plan for a recently admitted resident, whose CPA review stated they were on section 117, had no entry in the home’s care plan under the section on details of court order or section, and the home’s care plan was otherwise incomplete. A risk assessment in respect of the very hot water in the home could not be provided for this resident on the day of the inspection, but was forwarded immediately afterwards and staff advised that it had in fact been in the separate risk assessment file. The home’s care plan for another of the residents tracked showed no evidence of being reviewed in the light of their most recent CPA review. One resident who self medicates did not have a risk assessment in respect of this. One resident explained that they had their own bankbook, and they were aware of the benefits they received. They advised that they kept money and the bankbook in the office. This resident attended the office during the day. They were asked how much money they thought they had locked away in the office, and they said they did not know, but offered a guess of £30 or £40.00. The resident had a purse that was locked in the safe and a written record of money in and out. Both totalled £40.00. A group of residents advised that they had a residents meeting every Sunday, to discuss “anything in the house that is going wrong”. Examples they gave were chores, the toilets, washing up, and when another resident’s behaviour was causing difficulties for the others.” The home’s QA reports received in the 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 11 year indicate that residents views are listened to in respect of recruitment of staff, however, residents did not appear to be aware that they were an important part of the process. This group was asked if they have an opportunity to participate in staff appointments, and whether their opinion was sought. They advised that they didn’t, but one said, “ It would be nice.” One of the senior staff on duty advised that they also have a weekly menuplanning meeting. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 12 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): 12,13,15,16,17 People who use this service can expect to be encouraged to maintain contact with family and friends, to be able to choose how they spend their time and to receive a balanced diet. Residents can expect to be supported to use community services and facilities. Residents are likely to be satisfied with their quality of life, but may not be enabled through suport and encouragement to have as full a life as possible. If they are not presenting any problems. EVIDENCE: It was observed through out the inspection, that all the residents came and went from the home freely. All residents assist with daily tasks in the home, to varying degrees. Participation in this reflected their needs and abilities, and was the core activity for a number of the residents. Two had daily living plans based on three day a week day care activities. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 13 One resident who had been out most of the day returned later from the brickyard at St. Clements Hospital, where they were said to attend three days a week. One of the residents tracked had attended the Caretakers House that day, and arrived home with a beef casserole they had cooked. They advised that they had been on the local community transport. This resident advised that they went to The Caretakers three days a week, did cooking one day, music and healthy living another, and reading and writing on the third. They had a medical appointment later in the afternoon. The resident had had their hair coloured and styled by a member of staff and had a number of very nice outfits in their wardrobe which they were keen to show. They advised that they had never taken much interest in what they wore or nice clothes before they came to live at the home. There is a small room upstairs with a computer, and a notice invites residents to use this and get support, but two of the residents spoken with said they hadn’t used this. The need to develop vocational interest had been identified by the officer undertaking regulation 26 reports, and with a time frame of June 2006 given. A senior worker advised that residents are regularly offered various activities within the local community, but most do not take them up, and often drop out at the last minute. A file had been started on local resources and activities. One of the residents tracked had planned to go to Yoga that day, but had decided against it. Another resident tracked had been out shopping with a member of staff, and they had brought the lunch for that day. This resident had taken money to stop out for coffee, but had decided not to. The third resident tracked had been out shopping in the morning and planned to watch television in the afternoon. Of the other residents, staff advised one had a relative visiting that afternoon. One resident was rostered to keep the kitchen tidy and fill dishwasher, and it was planned that they would do their own washing and clean their bedroom, with some assistance. An older resident had been out on their own for early in the morning, staff advised that they do this every day, and again in the afternoon, but had no organised activities. A recently admitted resident went out during the day to do shopping for the home; they went with a member of staff and it was explained that this was because there were some additional items and they considered that they needed to give support. Staff advised that the resident planning to move in with family had been introduced to an advocate, to assist the resident determine whether this was their own choice. The resident concerned confirmed that they saw the advocate about March time, and that they asked them questions about living. They said that they enjoyed talking to the advocate, and were sure that they wanted to move to live with their family. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 14 One resident’s daily pattern was to go out once in the early morning, and once on the afternoon, but who had no other activities they regularly participated in. One member of staff advised that they thought they could do more with this resident, who they said was “ alright” but who se daily routine involved twice daily walks out on their own, and who otherwise sits and smokes. They attributed this to staffing pressure. The last entry on this resident’s daily notes, which are not completed every day for every resident was the 6th of April, Twenty-two days prior to the inspection. The home has one smoking room, and residents can smoke in the garden. One of the residents rooms seen had tea making facilities, they advised that they entertained their relatives in their room, which had two easy chairs positioned in front of the bay window. They advised that all of their family visit them at the home, although not all of them visit very often. When asked when they could visit, they said “they can come at quarter to ten at night if they want to.” Residents had a key to the front door and a key to their own rooms. One resident advised that staff “are ever so good, they never come in without knocking.” Another resident who had previously lived in another home said, “ I think everyone is treated well, better than the other place I lived at Residents and staff advised that some resident’s cook for others, and also that residents can help themselves to food. One resident advised that the food was “brilliant, fresher”. They explained that they had the freedom, if they didn’t want to eat a meal, to help themselves later, and that the freezer was full of nice things. Another who was very positive about all aspects of living at the home said, “I like the food as well.” Another resident said, “You can get up and make yourself a cup of tea or coffee or something to eat”. The residents spoken to all said that they were involved in the preparation and clearing up, or cooked their own food. The staff are supportive of helping the residents to make sure they have a good balanced diet; this was recorded in the care notes of one of the residents tracked. A member of staff prepared quiche and new potatoes for lunch on the day of the inspection. There was a well stocked fridge and freezer. There was a menu for the week for the main meal, which included roast chicken on the Sunday, cottage pie and fish pie, and a takeaway one day. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 15 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): 18,19,20 Residents can expect their physical and emotional needs will be met in a way they require and prefer. The homes medication administration practices do no fully protect residents. EVIDENCE: Two of the residents tracked and spoken with described receiving a level of personal support that maximised their independence, but account for their needs and vulnerabilities. The group of residents spoken with confirmed that they could get up and go to bed at whatever time they liked. One was receiving support and supervision to keep their room tidy, and store some items outside of their room as piles of clutter had been identified as a fire risk. The resident was keen to show what they were achieving, the condition of the room indicated an acceptable compromise had been found. Resident’s plans showed on going contact with community mental health services and with general medical services. One resident advised that they were going, accompanied by a carer, to a G.P. appointment, and left to attend this later in the afternoon. They advised that they attend a monthly appointment to have their blood pressure checked, and that when it was high they went every week. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 16 Another resident that was tracked had an accident logged in the accident book when they had collapsed. The residents record noted that the home was working on improving the residents diet and also that they had seen a General Practitioner. The records also showed that they were working closely with the psychiatrist, and a senior carer advised that they were hoping that they would be able to increase the residents’ independence. A resident who was from a minority ethnic group has been given a black key worker. They were asked whether this was helpful, and advised, “ I don’t mind at all.” The resident said that they didn’t mind what colour the key worker was, but that they liked having a man, and that it was better than having a woman. They described their key worker as a very nice man, and spoke about the help they received from them. The home’s visitors book showed regular professional visitors from the NHS Trust, the Community Mental Health Team and the Outreach Team. The other resident tracked spoke of their key worker and said; “ … is so good, ever so nice, so pleasant …can’t do enough for you,” adding “ they’re all nice.” The homes medication system had changed to a Boot’s system. One resident came to the office to receive their lunchtime medication. Staff ensured they had a glass of water to take them with, and they were given from the boots directly from the blister pack. The medicine administration records (MAR sheets), for all residents for the last five days were inspected. They were well kept, and there was a sheet for each medication prescribed giving details of the medicine and what it was for kept with the records. There were specimen signatures of those who administer medication. Stock levels were checked against ongoing records made on a daily basis on the MAR sheets. Staff advised that resident’s medication was only pre-prepared, using a “finger”, if the resident is going to be out for the day. This was checked with the manager as this did not comply with advice given by the pharmacy inspector to the organisation. The manager advised that they had not seen a copy of a letter to the responsible individual in June 2005 which set out this advice. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 17 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): 22,23 Residents complaints are likely to be treated appropriately, howver they are likely to find that the home responds to issues as they arise and that they do not need to use the formal poicy available. Residents are not be protected as fully as possible by environmental factors or risk assessments. EVIDENCE: The home had an appropriate complaints policy. The complaints policy was prominently displayed on the notice board just inside the main door into the home. The home maintained a complaints book; the last complaint received was in May 2005. One of the residents spoken to said that they would speak to their key worker first if they were not happy. Another said that they didn’t think they would need to make a complaint, but that if they did they would make it to the manager. One resident said, “ I wouldn’t want to make a complaint, I wouldn’t do that, I’m happy with everything.” A requirement was made in November 2005, following thefts from the home, and again following the inspection in January 2006, when the front door was found to be wide open, that the security of the building must be maintained. As noted in the last inspection report, there is also a risk form the fact that the home has four entry doors that residents requiring to go out, could go out without the staff knowing. On this occasion, all of the doors were found to be closed, but the front door was not secure and the Inspector was able to walk straight in. The Registered Manager advised that crime prevention team had visited and advised that the building is not easy to keep secure. They had 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 18 previously responded to the requirement by advising in writing that all residents have a front door key and are risk assessed regularly with regard to their and other’s safety with regard to entering and leaving the premises. The senior on duty during the morning advised that they had brought in a rule that the front door had to be locked during the day, and that they go round and do two or three checks during the day. The manager and the member of staff appointed to the deputy post had both received training in the protection of vulnerable adults (PoVA), as had a number of other staff. The induction course available for new staff included this subject. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 19 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): 24,25, 26,27,30 The home environment is not all to a good standard, but areas that have been renovated and decorated are to a good standard, and the ongoing works are not troubling residents. Residents may find that the security of the building is not maintained to a satisfactory standard. EVIDENCE: Keeping the home being homely, comfortable, clean and hygienic, is difficult for the home to maintain, as the major refurbishment work continues. On this occasion the home was found to be free from any inappropriately stored building materials. The areas of the home that have been completed are of a high standard and the communal space which is on the lower ground floor level in both homes, a dining room and a sitting room were clean and attractive, The covers to the three piece suite had been recently washed, and the room looked very bright and attractive. This room had a large television set. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 20 The laundry had recently been built and was in a good state of repair. There were two locked cupboards, and the resident assisting advised, “ that’s where they keep all the thingme stuff, you know, things we mustn’t have left about.” No substances hazardous to health were seen elsewhere in the home. The kitchen which had been refurbished quite recently was also in a good state of repair. Both were clean and tidy. There was fresh vegetables in the fridge, and any food that had been opened was covered. Fridge and freezer temperatures were kept, and a record added to record any action taken if a high reading was taken; i.e. a follow up temperature check. There was an environmental risk assessment for the kitchen. Two residents’ rooms were inspected; both were appropriately furnished to the taste and style of the occupants. There was a resident’s pay phone, with large numbers, in one of the hallways. The corridors and stair well other part of the home was shabby in appearance and some of the carpeting dirty and stained. There are two toilets and bathrooms on each floor where bedrooms are situated. The ground floor provides toilet facilities accessible from communal areas. Each toilet and bathroom is provided with a hand washbasin, hand wash gel and disposable hand drying towels. Bathrooms are provided with showers or baths, and some provide both shower and bath, so providing residents with choice of bathing facilities. All toilets and bathrooms were viewed to be very clean. Communal toilets had paper towels and liquid soap, but there were two part used bars of soap in one bathroom. A bracket on the top of the stairs, which had been identified at the last inspection as posing a risk to residents had been removed. One fire door on a stair well had had a new handle fitted, and there was a hole part way through the door opposite where one handle was. One storage cupboard next to the stairs was not marked as a fire door; the fire risk assessment was requested so that these two matters could be looked at in the light of the assessment, but the manager was not able to locate it. Two pages, only of a 6-page fire risk assessment dated 26/11/04 were available. The hot water temperature at one of the baths, where there was a notice stating “ very hot water” was 56.3 degrees Celsius. The resident showing the inspector around said that they found the water temperature was just nice, and explained how they could mix it and add more. This was spoken about with a member of staff and the manager, both of whom impressed that residents had complained when they had lowered the water, when this issue was first raised by CSCI. The member of staff advised that they went through using the water for bathing with residents in detail, and that they all had risk 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 21 assessments. A risk in respect of this was seen for one resident chosen at random, but was not present for the most recently admitted resident. One resident advised that they didn’t feel that the refurbishment work was affecting them in any adverse way. Another resident said that “cleanliness is a lot better than it used to be”, and in particular` that the toilet was better than it used to be. This resident advised that they were going to have their room redecorated, and had been offered a new carpet. They pointed out a new sink/vanity unit that was in their room waiting to be fitted. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. 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): 32,33,34,35,36 Whilst staff were seen to cope with the demands of the day, there were shortfalls of required activity in recording, including and the lack of evidence of any ongoing support in developing their lifestyle for one older resident. Residents are likely to experience the staff to be helpful and appropriate. EVIDENCE: Staff work either early or late shifts which run from 8.30 am to 4pm. and 1.30 to 9 pm. There is one sleeping in worker who covers from 9pm to 8.30 am, having worked the previous afternoon shift and then covering the following morning shift until 1.30. On the day of the inspection, the Registered Manager was on duty but was off site at a meeting; she returned at the end of the afternoon. One senior carer was on duty until 1.30, with a relief carer who was out with one of the residents during part of the morning. The relief carer worked through until 4pm. Two senior carers were on duty between 1.30 pm and 9 pm, and one of these was rostered to do the overnight sleep in. Staff advised, and the manager confirmed, that they were awaiting a Criminal Records Bureau (CRB) check for a worker they wished to appoint, and that they also had another vacancy. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 23 The staff on duty reflected the rota, which was inspected. It showed that during the week of the inspection that, including the manager, there had been only 2 members of staff on either the early shift or the late shift each day, apart from Wednesday when all were in for a meeting, and 3 on the alternative shift. This included a relief member of staff on some days. Some staff spoken with felt that there should be three workers plus a manager on duty. They explained that if one member of staff was out with a resident, supporting them in the community, this only left one carer to cover the general care in the home and all other residents when there was only 2 on duty. They advised that the actual level of staffing they had recently was “alright” as long as everything went to plan. This view was supported by the experience if the Inspector at their first attempt to conduct an Inspection in January 2006, when a resident was in the process of admission to hospital, and the inspection was postponed. Some staff thought that the additional paper work that the job increasingly involved made it difficult for them to cover all of their responsibilities, as they would like to, particularly in respect of work with residents. The senior advised that between 1.30 and four there were often four or five staff in, and on the day of the inspection there were three during this period, plus the manager. Through out the day the carers on duty responded to staff who called into the office, as well as participating in planned tasks with residents. Care staff held key worker roles and special areas of responsibility. Two that were on duty during the afternoon of the inspection shared a lead role for medication. Other areas of responsibility delegated to named members of staff included infection control and food hygiene, control of substances hazardous to health and fire safety. The recruitment files of two staff on duty were inspected. Both had two references on file, received before employment started. Both had application forms and contracts. Both had evidence of PoVA first checks having been received prior to employment. The manager advised that Criminal Records Bureau checks are not kept after they have been seen. There was no document on file to show that these had been received, when they were received, or that they were satisfactory. The senior on duty advised that staff training needs were identified at appraisal; and that they were aware that the manager was working on ensuring that training provided would meet the needs of the service. The advised that a new learning and development programme had been provided by Together; Working for Wellbeing. This included induction based on skills for care standards: there were four two-day courses to be held in London, spread throughout the year. Other training available was comprehensive. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 24 A senior member of staff who had been appointed as a deputy had not yet taken up this position advised that the situation with NVQs remained the same as at the last inspection, when it was evidenced that four staff were doing their National Vocational Qualification level three. They advised that two had nearly completed, two were half way through. They advised that the home did not currently have a training analysis, but that they understood that the manager was currently working on this, to fit in With Together; Working for Wellbeing’s new system. Training certificates evidenced that the manager, deputy manager and a number of other staff had attended POVA training. During the inspection, the files of the two newest members of staff were looked at. Both files had a photo of the member of staff on the front of the file and basic information. There was the three-month probationary report signed by the member of staff, job application, contract of employment, firm offer letter and two references. The files also had emails confirming that the staff had Criminal Record Bureau and the Protection of Vulnerable Adults first check. Also on the files were, GP details, interview checklist, medical check and photocopies of proof of identity. The senior on duty advised that records of supervision were held by the members of staff who supervised them, but one of the members of staff on duty was able to access records of their own supervision that another member of staff had undertaken. This record had a supervision contract on file, and regular supervision on a two monthly basis for the first 6 months of 2005, but nothing there after. They advised that the manager had subsequently undertaken two or three. This member of staff also provided records of supervision they had undertaken with a member of staff, they had held five sessions since September. Regular weekly staff meetings were held, and record of these were seen which supported information given by staff that policy matter and residents welfare were discussed at these meetings. A member of staff advised that currently one resident was discussed at most meetings, but that not all will be discussed in depth. A handover meeting was held when the shifts changed over at 3pm, and each resident was discussed, some in more depth than others. Residents spoken with all advised that they found staff to be very good, and to support them in a way they found acceptable. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 25 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): 37,39,42,43 Residents can expect that they benefit from a home that is generally well run, and wherein their views underpin all self-monitoring, review and development by the home. EVIDENCE: Staff spoken to advised that they had felt the need of a Manager, having had to manage with a vacancy in this position for over six months prior to Janet Gentry having taken up post. Janet Gentry commenced as manger in November 2005, had been approved as Registered Manager since the previous inspection. On this occasion she was able to provide evidence of having received Protection of Vulnerable Adults training. One resident said of the new manager, “ I love her, she’s like a mum for you, she’s got time, she comes and talks to me.” 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 26 Fire extinguishers were seen to be next due for a service in June 2006. A resident explained that every one goes out when there is a fire drill. A record of weekly checks on the automatic fire detector was available. There was also a record of fire drills and evacuations. Emergency lighting was checked by an external company twice a year. A Portable Electrical Appliance booklet showed that these had been carried out and were next due in October 2006. The fire risk assessment, however was not available, and the home was not secured at the time of the inspection. The home’s Certificate of Registration was not displayed and could not be found on the day of the inspection. Detailed Regulation 26 reports, including the organisations own Quality Assurance exercise on a key standard had been undertaken and a copy provided to the CSCI regularly up until the last two months, when they had not been undertaken. A member of staff advised that resident questionnaires and a questionnaire to relatives go out centrally from Together; Working for Wellbeing. They advised that these had recently come to the home to give out. These have previously been used in the organisations business planning, and an annual report sent to the CSCI. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 27 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 3 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 2 25 3 26 3 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 2 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 28 YES 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 YA6 Regulation 15(1) Requirement Residents individual care plans for the home must be completed in a timely way following admission. CPA reviews must be obtained in a timely way and the home’s care plans reviewed in the light of them. Regular frequent recording on daily notes must be present for all residents, to monitor their well being in relation to their care plan. All residents must be assisted to take part in valued and fulfilling activities. Wherever possible, medicines for residents on short and longerterm leave from the home must be provided by arranging a separate container with the supplying pharmacy. Where this is not possible, for example, a resident’s leave at short notice, the member of care staff may be justified in supplying a small number of doses in a compliance aid where all other options have been explored. Full records of such professional justification DS0000048200.V291721.R01.S.doc Timescale for action 31/05/06 2 YA6 15(2)(b) 31/05/06 3 YA6 17(3) 31/05/06 4 5 YA12 YA20 16(2)(m) 13(2) 30/06/06 14/06/06 4 - 6 Cavendish Road Version 5.1 Page 29 should be made. 6 7 YA20 YA23 13(4) 13(4)(a) Risk assessments must be in place for any resident who self medicates. The registered manager must ensure that the security of the building is maintained at all times. This is a repeat requirement. The home must consult with the fire authority in respect of a fire door on the stairwell, where a change in the position of the handle had compromised its width. Bars of soap must not be left in communal bathrooms. Evidence that Criminal Records Bureau checks have been undertaken, showing when they were received, and that they were satisfactory must be kept on staff files. Records of formal supervision must be maintained. The home must have a fire risk assessment available, a copy must be forwarded to the CSCI. Regulation 26 visits must be undertaken at least monthly. The home’s Certificate of Registration must be on display. 28/04/06 28/04/06 8 YA24 13(4)(a) 28/04/06 9 10 YA30 YA34 13(4)(c) 19(1)(b) sch 2 31/05/06 31/05/06 11 12 13 14 YA36 YA42 YA43 YA37 18(2) 13(4)(c) 26 C S Act 2000 31/05/06 28/04/06 31/05/06 28/04/06 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 Refer to Standard YA8 Good Practice Recommendations The value of residents input into decisions regarding staffing appointments and new residents placements should be reinforced. DS0000048200.V291721.R01.S.doc Version 5.1 Page 30 4 - 6 Cavendish Road 2 YA33 The pattern and levels of staff deployment should be reviewed. 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 4 - 6 Cavendish Road DS0000048200.V291721.R01.S.doc Version 5.1 Page 32 - 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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