Inspection on 29/04/08 for Ca Na Gardens

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ca Na Gardens 17/11/09

Ca Na Gardens 28/04/09

Ca Na Gardens 18/12/08

Ca Na Gardens 27/11/08

Ca Na Gardens 23/05/07

Ca Na Gardens 23/05/06

Ca Na Gardens 19/09/05

Ca Na Gardens 16/05/05

Ca Na Gardens 08/10/04

Ca Na Gardens 07/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Ca Na Gardens 174 Scraptoft Lane Leicester LE5 1HX Lead Inspector Diane Butler Unannounced Inspection 29th April 2008 09:30 Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 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 Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 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. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ca Na Gardens Address 174 Scraptoft Lane Leicester LE5 1HX 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) 0116 2413337 0116 220 2772 Biggsy_31@yahoo.co.uk Hamra Associates Limited Mr Ray McLaughlan Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 23rd May 2007 Brief Description of the Service: Cana Gardens is a care home providing personal care and accommodation for up to eight people with a learning disability. The home, which is located on the outskirts of Leicester city centre, offers six single rooms and one shared room. Communal facilities include a lounge and a separate lounge/dining area. Both of these rooms have patio doors, which lead onto a large garden to the rear of the home. There are a variety of local amenities close by including a large supermarket, small local shops, health centres, temples, churches and takeaways. Current charges are £344 per person. Inspection reports regarding the home are available and can be accessed via the CSCI website: www.csci.org.uk. A copy of the most recent inspection report is also displayed in the reception area. Further information about the home is available from the registered manager. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use the service experience adequate outcomes. This was an unannounced visit, which took place over a 5 hour period in April 2008. A further announced visit also took place in order to meet with the registered manager. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for service users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, speaking with them and discussion with staff on duty at the time of the visit. Where communication was difficult observation was used to evidence whether care needs were being met. Further planning for this visit included checking the service history of the home and the last Inspection report and looking through the AQAA document (Annual Quality Assurance Assessment), which was submitted to the Commission for Social Care Inspection prior to the visit. The AQAA document is the main way that providers inform us of how well their service is delivering good outcomes for the people using it. Surveys were also sent to the service users currently living at the home and their relatives and a selection of support workers to gain their views of Cana Gardens. One service user survey and four support worker surveys had been returned at the point of this inspection visit taking place. Comments received include: “I feel the service we do is good, it is a relaxed and happy home”. “Our work place is a small close knit caring place, we have staff that have been here for years so the service users are close to all staff, so they feel safer and secure and that makes a happy home for them”. “I feel the service could do more in day trips like hiring a mini bus and take all the clients to the seaside or the zoo, there are many lakes around Leicester where you can walk around and feed the ducks”. “Provision for activities for male residents is good”. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Update the statement of purpose document and complaints procedure and make these available in easy read format. Service users need to have up to date information that they can understand at all times. Ensure that the residents care plans and associated documents are reviewed and are kept up to date and accurate. Support workers need to have up to date information to enable them to care properly for the service users Ensure that risk assessments carried out are kept up to date and accurate at all times. Support workers need to be aware of all the current and ongoing risks to the service users and the actions to take to minimise those risks. Ensure that accurate, complete and up to date records are kept of all medication administered to service users to ensure that medication is administered safely, correctly and as prescribed. Service users need to be protected by accurate medication management and record keeping. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 7 Ensure that a record of all complaints, and the actions taken in respect of those complaints, are kept. The registered person must demonstrate that complaints are taken seriously and investigated appropriately. Ensure that the persons employed by the registered person working at the care home receive training appropriate to the work they are to perform. Support workers need to be appropriately trained in order to support the service users in their care. Ensure that records held in respect of each service user are thorough, accurate and up to date. Support workers need to have up to date information to enable them to care properly for the service users. Contact the local pharmacist regarding the current storage of medication. This will ensure that medication is being stored in line with current guidance provided by the Royal Pharmaceutical Society. Ensure that a record of food provided for service users is kept in sufficient detail to enable the reader to determine whether the diet provided is satisfactory. Provide further training in safeguarding this will ensure that all staff are aware of their responsibilities. 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. The summary of this inspection report can be made available in other formats on request. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 8 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 Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users needs are assessed before moving into the home to ensure that they can be met. EVIDENCE: A Statement of Purpose is in place. This document, which was last reviewed in 2006, includes details of the services that can be provided, the process for any new service users moving into the home and details of the complaints procedure. It was noted that this document is not available in easy read format, which could help people to understand it more. No new service users have moved into home since the last inspection in May 2007. Three service users files were checked. All included an initial assessment/care plan, which had been prepared by the service users social worker before they had moved in. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 10 The homes own documentation is in the form of an outlined assessment and care plan, which is produced from the social workers initial assessment/care plan. All three files included one of these documents. Service users spoken with during the last visit and information included in surveys received prior to this visit stated that they were able to look around the home before they moved in to see what it was like. Each service user has a terms and conditions of residency in place which tells them how much it costs to live at Cana Gardens and what services are included in the fee charged. It was noted that these were not up to date and didn’t show the current fees charged. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although service users individual needs are currently being met, up to date care planning would ensure that any changes in their care and support needs would be identified and addressed. EVIDENCE: Care plans and person centred plans were in place. Care plans included information on the individual support needs of each service user and also identified the tasks that they were able to carry out to support themselves. It was noted that all care plans checked were in need of updating. Some care plans had not been updated since their last review in June 2007 and those that were due for a review in January 2008 had yet to be completed. Person centred plans were also in place, however, these varied in content and again were in need of updating. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 12 Support workers enable the service users to take responsible risks on a daily basis and risk assessments are in place for activities undertaken. It was noted that the majority of these had not been reviewed recently. The registered manager explained that he had recently commenced reviewing all of the care plan documentation to ensure that it was up to date and relevant. Two new risk assessments had been developed recently for two of the service users whose files were checked, these had been carried out because of risks that had been identified whilst out on trips to the local park and when out in public. Service users living in the home are able to make decisions on a daily basis, these include when to get up and when to go to bed (when they are not attending organised day care services) what to wear, what to eat and where to eat it, and what activity they wish to complete in their free time. Service users are involved in life at the home and issues that arise are discussed on a daily basis. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to attend and participate in appropriate activities. EVIDENCE: Seven service users are currently supported to access local day services during the week, this includes sessions at Layton House and Thurnby Lodge day centres, St Albans cultural group, Netheral Neighbourhood Centre and Weston Park and Fosse Park Community Centres. The remaining service user is provided activities by the staff on a one to one basis within the home setting. This includes visits to the local parks, shopping, swimming and going for walks. Records of these activities, which are planned for on a day to day basis, are kept within the service users file. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 14 It was noted that daily activity timetables included in the care plans were not all up to date, particularly for one of the service user who has recently been provided with day care services twice a week. Daily routines within the home promote privacy and choice. Service users can choose whether to be alone or join the other service users, they are encouraged to assist in the daily chores of the home and for those service users who are able, are supported do their own laundry. During the visit one of the service users helped to do the washing and drying of the pots from the evening meal. A balanced diet is offered, service users are able to choose what to eat on a daily basis and mealtimes are unrushed and flexible. During the visit it was evident that mealtimes are both relaxed and informal and the service users had the opportunity to choose what to eat. Currently there are two sittings for the evening meal, to cater for those residents who prefer English food and those who prefer Asian food. The evening meal offered during the visit was a choice of meat pie or chicken with fresh vegetables and lentils with rice. One resident chose not to have either of these choices and was accompanied to the local kebab shop for a kebab instead. It was noted that there is currently no record of the meals being provided. The support workers monitor the service users weight on a monthly basis and healthy eating is encouraged on a daily basis. On checking the weight record belonging to one service user it was noted that they had lost one stone in less than three weeks (this was not acknowledged in the daily records). The registered manager felt that this was an error either with the scales used or in the recording. A discussion took place with regard to the importance of reporting, recording and responding to such issues. Visiting is strongly encouraged and service users can choose to meet with their visitors in one of the lounges or in their own room if they wish. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care and support is provided in the way the service users prefer. Lack of accurate information within medication records could result in errors being made. EVIDENCE: Service users are encouraged to be as independent as possible, for those less able to care for themselves, support and guidance is offered in a sensitive manner. The senior care worker explained that whenever possible male support workers provide personal care for the male service users and female support workers provide personal care for the female service users. Service users are able to choose when to get up and when to go to bed, particularly at the weekends and are encouraged to choose what to wear. Support workers assist the service users to access healthcare services when needed, these include the local GP’s, opticians and community nurses. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 16 Service users spoken with stated that they were treated well and received the care and support they need. One service user stated, “They spoil me sometimes”. Medication records were checked. Medication had been appropriately signed into the home and on the whole the medication had been appropriately signed for when given to the service users however, there was one recording error regarding a medicine given as and when required (PRN). It was noted that the MAR (Medication Administration Record) chart stated that 28 Lorazepam tablets had been signed into the home on 11/04/08, it also stated that seven tablets had been given to date thus leaving 21 tablets, on checking the tablet box it was noted that there were in fact 22 tablets left in the box. A discussion took place with regard to the use of PRN medication for one service user, the inspector was informed that the service user had had a review regarding this medication in the last two months and the Doctor involved in the service users care was happy for its continued use. It was also noted that a medication recently started by one of the service users had been inappropriately recorded on to the MAR chart. The MAR chart simply stated ‘iron tablet’ and did not include its full name, strength or full instructions as per pharmacists request. All but two support workers have received training in the administration of medicines, the remaining two are booked to attend training from the local pharmacist on 21st May 2008. Medication is currently stored in a small lockable cupboard on the office wall; it is recommended that this be checked out with the local pharmacist to ensure its suitability. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users feel safe. Further training would ensure that all staff are aware of their responsibilities within safeguarding. EVIDENCE: A complaints procedure is in place and a copy of this is included in the Statement of Purpose. It was noted that this document was not up to date and not available in easy read format, which could help people to understand it more. The service user spoken with on the day of the inspection confirmed that they felt safe in the home and stated, “I would talk to xxxxxx (the senior support worker) if they were worried about anything. On checking the complaints file it was noted that no complaints had been received since the last inspection in May 2007, however on checking the staff meeting minutes it stated that two complaints had been received regarding the environment and the cleanliness of the home. These had not been recorded in the complaints file. A safeguarding referral is currently being investigated. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 18 The majority of support workers have completed safeguarding training though it was evident that the most recent support worker who commenced work in January 2008 had yet to complete this. It was also noted that one of the support workers spoken with during the visit couldn’t remember whether they had received this training or not. All support workers spoken with during the visit were aware of the actions to take should they suspect any form of abuse was taking place in the home. Money held on behalf of the service users was checked. Due to shortfalls identified by Leicester City Council within the management of service users money, a new system is currently in place. Records and receipts are kept for all purchases made and at the end of each month an invoice is sent to them and all money spent is reimbursed. Service users do not currently have individual bank accounts as identified at the last inspection, the registered manager explained that this was currently being looked into. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with a comfortable place to live. EVIDENCE: Cana Gardens provides accommodation for up to eight service users with six single bedrooms and one shared room available. There is a lounge, dining room and kitchen on the ground floor for the service users to use and patio doors lead to a large garden to the rear of the home which service users have full access to. Shower and bathing facilities and toilets are available on both floors. Decoration and furnishings in the communal areas are comfortable and service users are provided with a relaxed and homely place to live. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 20 The room belonging to one of the service users spoken with was seen during the visit. This was clean, appropriately furnished and included their own personal belongings. It was noted that a number of doors on the ground floor were being held open with door wedges it is recommended that this is checked out to ensure that this is acceptable practice. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are currently supported by a competent staff team, however further training would ensure that they have the appropriate knowledge and skills to meet the service users individual needs. EVIDENCE: It was evident during the visit that the support workers were well aware of the needs of the service users and of their roles and responsibilities within the home. All support workers are given a copy of their job description during the recruitment process to ensure that they are fully aware of what is expected of them once employed. An appropriate recruitment procedure is in place, application forms are completed, references are collected and a POVA 1st (Protection of Vulnerable Adults) check and CRB (Criminal Records Bureau) check are obtained. The senior support worker explained that a period of induction is provided to all new support workers, this includes both an in house induction, learning Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 22 about policies and procedures and routines of the home and a formal induction training entitled ‘First Steps’. Of the two most recent support workers to commence work in the home only one had commenced this. The senior support worker stated that the support worker who commenced work in January 2008 was due to start their induction the following day. On checking the training records it was noted that a number of training sessions have been provided including food hygiene and handling of medicines, however it was noted that the record was not up to date as it still included staff members who no longer worked at the home and didn’t include the two most recent members of staff to be employed. Two support workers spoken with stated that they had received infection control and health and safety training since the last inspection in May 2007 but both stated that they had not received any training in the Protection of Vulnerable Adults or whistle blowing. On checking daily records it was noted that a number of the residents display both aggressive and challenging behaviour, which affects other service users and support workers. It was noted that one incident had taken place on a bus when one a support worker had taken a service user out who is known to display aggressive behaviour, the actions carried out by the support worker to diffuse the situation were questioned as suitable. No evidence was found to show that the support worker had received induction training or training in handling aggression. The registered manager explained that the support worker had received training in challenging behaviour prior to being employed at Cana Gardens but no evidence was available to confirm this. A second incident occurred when a service user grabbed a support worker at the top of the stairs and tried to throw them to the bottom, the support worker used mild restraint to remove the service users grip. On checking the training records and discussion with three support workers it was evident that training in these areas has not been provided. On speaking with the registered manager after the visit we were informed that he was in the process of sourcing training in dealing with challenging behaviour and all staff would be attending. Further training booked includes ‘learning disability, a positive approach’ which is booked for June and October this year and medication training is booked for later this month. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 23 On discussion with one support worker it was evident that although one of the service users suffers with epilepsy, not all staff have received formal training to enable them to support the service user with this condition. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Not all records required by regulation for the protection of the service users are up to date or accurate. EVIDENCE: A registered manager is in place though the hours that he works are not currently included in the rota. We were informed that he visits the home on a regular basis to support the staff working in the home. The homes administration manager has been on long term leave and it was evident that because of this not all records were up to date or accurate. This includes service users care plans and daily activity sheets, risk assessments, accident records, complaint records, medication records and training records. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 25 Risk assessments were in place for safe working practices, though it was noted that some had not been reviewed as required. The senior support worker on duty during the visit stated that staff meetings are held and this was confirmed on speaking with other support workers and on checking minutes taken at the last meeting held on 29th April 2008, though it was noted that only the manager and the senior support worker attended on this occasion. The senior support worker stated that supervision sessions are provided and this was confirmed on speaking with support workers, on checking staff files and on review of information in three staff surveys received prior to this visit. A monthly information bulletin has been developed and this is given to all staff providing them with relevant information about the home, reminders of their responsibilities and best practice issues. On checking the daily records belonging to three service users it was noted that these did not fully correspond with the accident records held in the home. On a number of occasions service users had suffered falls but these had not been included in the accident records. Details of how the falls had happened, when and where these had happened or details of the effects the falls had had on the residents had not been recorded. This was discussed with the registered manager who stated that he would look into this. It was noted that some of the daily records included inappropriate wording, this was discussed with the registered manager who explained that he has updated the guidance on recording and reporting and has been addressing this issue within staff meetings. Support workers spoken with stated that they felt supported by the management team. One service user stated: “I like Raymond, he’s a good man” [registered manager]. Policies and procedures for the health, safety and welfare of the service users are in place. Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 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 3 X 3 X 2 2 X Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 6(a) Requirement The registered person shall – keep under review and where appropriate, revise the statement of purpose. The registered person must ensure that the statement of purpose document is up to date and accurate. Service users must have up to date information at all times. The registered person shallKeep the service user’s plan under review. Where appropriate and unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his revise the service users plan. The registered person must ensure that the residents care plans and associated documents are reviewed and are kept up to date and accurate. Support workers need to have Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 28 Timescale for action 09/06/08 2 YA6 15(2)(b) 26/05/08 15(2)(c) up to date information to enable them to care properly for the service users 3 YA9 13(4)(c) The registered person shall ensure that: Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The registered person must ensure that risk assessments carried out are kept up to date and accurate at all times. Support workers need to be aware of all the current and ongoing risks to the service users and the actions to take to minimise those risks. 4 YA20 13(2) The registered person shall make 26/05/08 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person must ensure that accurate, complete and up to date records are kept of all medication administered to service users to ensure that medication is administered safely, correctly and as prescribed. Service users need to be protected by accurate medication management and record keeping. 5 YA22 17(2) The registered person shall – maintain in the care home records specified in Schedule 4. 26/05/08 26/05/08 Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 29 The registered person must ensure that a record of all complaints, and the actions taken in respect of those complaints, are kept. The registered person must demonstrate that complaints are taken seriously and investigated appropriately. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users – Ensure that the persons employed by the registered person working at the care home receive training appropriate to the work they are to perform. Support workers need to be appropriately trained in order to support the service users in their care. The registered person shallMaintain in respect of each service user a record, which includes the information, documents and other records specified in Schedule 3 relating to the service user. The registered person must ensure that records held in respect of each service user are thorough, accurate and up to date. Support workers need to have up to date information to enable them to care properly for the service users 6 YA35 18(1)(c) 26/05/08 7 YA41 17(1)(a) 26/05/08 Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 30 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 YA1 Good Practice Recommendations The registered person should ensure that the Statement of Purpose and complaints procedure is available in a format that is easily understandable to prospective service users and their families. The registered person should contact the local pharmacist regarding the current storage of medication. The registered person should ensure that a record of food provided for service users is kept in sufficient detail to enable the reader to determine whether the diet provided is satisfactory. The registered person should provide further training in safeguarding to ensure that all staff are aware of their responsibilities. 2 3 YA20 YA17 4 YA23 Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ca Na Gardens DS0000006360.V363428.R01.S.doc Version 5.2 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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