Inspection on 26/06/08 for Cadogan Court

This inspection was carried out on 26th June 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cadogan Court 09/07/09

Cadogan Court 06/07/06

Cadogan Court 10/02/06

Cadogan Court 14/10/05

Cadogan Court 20/01/05

Cadogan Court 20/07/04

Cadogan Court 04/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Cadogan Court Barley Lane Exeter Devon EX4 1TA Lead Inspector Rachel Doyle Unannounced Inspection 26th June 2008 08:45 X10015.doc Version 1.40 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 Cadogan Court DS0000026703.V364916.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 Older People. 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. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cadogan Court Address Barley Lane Exeter Devon EX4 1TA 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) 01392 251436 01392 410097 kfender@rmbi.org.uk www.rmbi.org.uk Royal Masonic Benevolent Institution Katharine Josephine Fender Care Home 70 Category(ies) of Old age, not falling within any other category registration, with number (70), Physical disability (70), Physical disability of places over 65 years of age (70) Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for up to 15 - OP with nursing Date of last inspection 6th July 2006 Brief Description of the Service: Cadogan Court opened in 1986, and now provides accommodation for a maximum of 70 people. It is registered to provide nursing care for up to 15 service users, and residential care for up to 70 service users, all of who should be over retirement age. The home does not offer intermediate care. A requirement for prospective residents is that they have professional links with the Royal Masonic Benevolent Institute (RMBI). The home is purpose-built, and stands in its own grounds on the outskirts of Exeter. There is some car parking space. The home has its own transport for residents’ benefit. A local shop and public transport routes are available nearby. The home has three levels, with lift access to all areas. There are various communal facilities around the home: several large lounges and smaller sitting rooms, a large dining room, kitchenettes, residents’ own laundry facilities, a library and a chapel. All bedrooms have en suite facilities. Weekly fees at the time of the inspection were £470 - £743. These did not include the cost of theatre outings/concerts (charged at 50 of the ticket price), magazines/newspapers (variable), toiletries (variable), hairdressing (£5), chiropody (£6) and aromatherapy (£2). General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . Inspection reports produced by the Commission (CSCI) about the home are kept at the reception, in the home’s entrance hall. Prospective residents may read these, and are also directed to CSCI’s website. Cadogan Court DS0000026703.V364916.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 2 star. This means the people who use this service experience good quality outcomes. This unannounced visit took place over 8 and 3/4 hours, one day towards the end of June 2008. The home had been notified that a review of the home was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. During the inspection 3 people were case tracked. This involves looking at peoples’ individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to people living at the home; representatives, health and social care professionals (including GPs and care managers) and staff. At the time of writing the report, responses had been received from 7 people living at the home. Their comments and views have been included in this report and helped us to make a judgement about the service provided. At the time of the inspection there were 66 people living at the Home, 22 were receiving nursing care on nursing wings as opposed to a residential placement. 1 was on a temporary basis and 3 were due to move in. During the inspection 6 people living at the home were spoken with individually and 7 in a group setting, as well as observing staff and people living at the home throughout the day. We also spoke with 4 staff and the deputy manager. The manager was on sick leave for 3 weeks. A full tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files. What the service does well: Pre-admission procedures ensure that the Home is clear that they can meet peoples’ needs before they move in. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 6 Care plans are generally very good and contain a lot of useful information including social care needs. Staff are knowledgeable about peoples’ needs and are well trained and supported by management. Staff felt that there were plenty of training opportunities and that they worked well as a team to meet the individual needs of the residents. There is a small competent and enthusiastic team lead by the Registered Manager, who expects the highest standards of care, safety, security and maintenance for everyone who lives and works at Cadogan Court. The Manager is a trained nurse with years of experience in the health and welfare of the elderly. She keeps high standards and finds opportunities every day to be available for the staff and senior team. She ensures that all staff have the right equipment to give the care that the clients require, she maintains an open door policy so that any member of staff feels that they are able to discuss any problem or difficulty. Management hold regular meetings with all sections of the staff team, residents, relatives and the Friends of Cadogan Court. Each department manager reports to the Registered Manager every morning. If there has been an adverse incident she listens and deals with the situation firmly but fairly. The environment is bright, clean and fresh. The home is well maintained and continuously being updated to improve facilities for the clients. The clients rooms are their home, and this is respected by all members of staff who only go into clients rooms with their authority unless there is an emergency. Mealtimes are very important to people and they are encouraged to socialise and sit with their friends. There are some people who prefer to eat in their own rooms and this is accommodated. The catering is all done on site by RMBI staff, and the chefs are able to produce diets suitable for the clients needs. They are well trained and have been on recent diabetic dietary training. What has improved since the last inspection? What they could do better: The Home could ensure that care plans contain clearer and more detailed information about peoples’ mental health care needs so that staff know how to meet these needs consistently and record care in an appropriate language. Any records relating to peoples’ bruising needs to be monitored and documented more clearly. Although there is an excellent activity programme the focus needs to be on the individuals to ensure that everyone living at the Home has an opportunity for Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 7 appropriate, regular and meaningful occupation especially those who are less able to ensure their well being. Generally people are enabled to spend their day as they wish and have their choices respected. Some people find that their choices are not always respected by staff that are not their key-worker especially if they have limited sight. Although incidences such as falls are well recorded these are not always audited to ensure that any patterns are looked at and preventative measures and actions put in place in a timely way. Although people fell that complaints are listened to and sorted out, the records need to be improved to ensure that they are more organised and can be audited and acted upon in accordance with the complaints policy and procedure. At present complaints are kept on bits of paper in the incidence file. 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. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are encouraged to visit the home and an assessment of the support they require ensures that the home can appropriately meet their care needs. EVIDENCE: Three pre-admission assessments were looked at on three peoples’ files, as part of case-tracking, and these covered a broad range of care needs, including skin care, social needs and continence issues. Residents confirmed that either they had visited prior to moving to the home or a relative on their behalf. The assessments contained information from a range of multidisciplinary sources such as social workers and hospital records to ensure Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 10 that the Home can meet peoples’ needs before they move in. The home does not provide intermediate care. The Statement of Purpose and Service Users’ Guide was not inspected but it was noted that although people at the Home are issued with a Guide on admission none of those spoken to had a copy to hand, which could be helpful for reference especially if they have a short term memory. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to improve RMBI marketing through established links through the Masonic movement in Devon, Cornwall and Somerset by giving talks at Masonic Lodges and attending Masonic functions, as their sole source of clients is through the Masonic movement. They intend to work closely with the marketing department at RMBI Headquarters to ensure there is modern marketing material. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well formulated and give clear information to enable staff to meet peoples’ health and social care needs. Improvements could be made in recording mental health care needs. People are treated with dignity and respect. The health and personal care needs of people living at the Home are generally well met by knowledgeable and friendly staff with evidence of good multidisciplinary working taking place where necessary. There are robust procedures around medication to ensure the safety of people living at the Home. EVIDENCE: Three care files were looked at as part of the case-tracking process. All plans showed good detail identifying peoples’ needs including information from the Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 12 pre-admission assessment, family knowledge and issues around peoples’ activities of daily living. Plans contained risk assessments (manual handling, general environment, falls and skin integrity), actions for staff, nighttime assessments and health professional appointments and records of any visits. All plans were regularly reviewed and kept up to date. This information ensured that staff were able to clearly meet peoples’ needs and showed that people living at the Home had been involved in the care planning process. Some mental health assessments needed expanding to ensure that staff are following clear plans. For example, one plan has ‘aggressive’, ‘inappropriate behaviour’ and ‘unco-operative’ ticked with no further explanation. There had been no adverse outcomes for the person in the Home despite this. One plan did not clearly address appropriate actions for someone living with dementia. This is being addressed and that person is being re-assessed to ensure that the Home is able to meet their needs. The deputy manager said that they were aware that staff were not as knowledgeable about mental health needs and that training has been booked to aid them. The Home have a General Practitioner (GP) surgery once a week and people make appointments as in a community general practice, visiting the GP room or in their own rooms as necessary. The chiropodist and aroma therapist were visiting during the inspection and people could ask staff to put them on the appointment list. Plans had clear information about MRSA (a particular infection) and staff were knowledgeable about the care needed. People living at the Home commented in the survey responses; ‘I am very happy here, Heaven on Earth’ and ‘98 out of 100, 4 star!’ One relative was impressed by the friendship and care by all the staff, calling the Home particularly well run and happy. People in the Home spoke positively about staff, which were described as ‘very good’, ‘cheerful’ and ‘lovely’. Discussion took place with people about how they were supported with washing and bathing and generally people said they felt they were treated with respect and their dignity respected. Staff demonstrated a good understanding of people’s needs and were able to describe good practice in relation to maintaining their privacy and dignity. All rooms are clearly named with a photograph of the occupant and preferred name. However, people who have limited or no sight felt that staff could be more aware of their needs such as remembering to say who they are when they pop in and who visitors are before they arrive or describe what was in their room. (see Standard 14). The deputy manager said that they would remind staff and confirmed that there is a key worker system in place and although staff move around the Home, peoples’ named key workers remain the same so that they can build up a better relationship with people. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 13 We observed part of a medication round, which showed good practice. There are sample staff signatures, which can show an audit trail and identification photographs of people receiving medication. All staff that administer medication have attended training by a local pharmacy. There are computerised administration records, which were filled in correctly and clear with no gaps. There was a safe, tidy and secure storage arrangement, including fridge temperatures and organised returns. Staff were able to discuss how they are trained in doing blood sugar readings with the District Nurse input. A Homely Remedy policy is in place so that people can be safely given medication that is not prescribed such as Paracetamol for a headache but this type of medication is generally prescribed anyway. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to provide further clinical teaching so that staff can identify clinical problems and bring them to the attention of the shift leaders before they become overwhelming and need hospitalisation. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Links with visitors and the community are good, giving opportunities to support and enrich peoples’ social lives. The Home generally offers a suitable range of activities and entertainments to stimulate and occupy people living at the Home. Meals were seen to be well presented, providing nutritious variety and choice for people living at the Home. EVIDENCE: The two activity organisers provide a wide range of activities for people living at the Home. On the day of the inspection a group were going off to a wellknown department store and a craft session was scheduled for the afternoon. The activity notice board described other opportunities to attend Bingo, Musical entertainments, music and movement, a donkey visit, flower planting and films. There had recently been the annual summer fair, which is a large event with a BBQ, cake stall taking place in the extensive grounds. People said that Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 15 they really enjoyed themselves and family and friends had been able to attend. The Home has two vehicles including a wheelchair bus and minibus. This takes people on a weekly supermarket shop. Activities are included in individual care plans along with peoples’ social history. Key workers are able to go through what activities people would like to do and what suits them. The care plans have monthly records about what activity people have been able to do. It would be good practice for the Home to focus on the individuals rather than the activities themselves. Although there is a very good activity programme, when we looked at the three individual care plans some people have had minimal stimulation especially if they often stay in their rooms or have some communication difficulties. Plans showed that some had attended 7 ‘activities’ in 34 days, 5 ‘activities’ in 31 days and 3 ‘activities’ in a month. When someone can’t or does not want to attend what is offered then it may be that they do not spend time doing very much. This could also be that staff are not recording one to one time with less able people or other things that promote well-being for people. One person said that they would like more ‘people-time’ and another person clearly needed to be kept busy to keep them well. However, overall the Home does very well in providing a good programme that also encompasses the Masonic feel. People were seen to be entertaining visitors, pottering around the Home and there was a lovely, homely atmosphere. Peoples’ rooms evidence that they are able to bring in personal possessions when they move to the home and during conversations they gave examples of making choices over their lives, which were confirmed by care records. For example, where they ate their meals, whether they have a portable call bell or whether they chose to attend the activities arranged. These views were echoed in the home’s quality assurance survey. Comments in our survey responses from people living at the Home included ‘they encourage visitors, my family are like their family’, ‘ I can do what I want like home, wonderful’ and ‘I’ve got lots of choice, it’s like my home there’s lots of things to do’. Two people with limited sight said that the key worker system was a good thing and that their needs were usually met but that staff needed to ensure that their choices are met even when the key worker is not on duty. Examples where this does not always happen were that one person would like to go out to smoke once a day, have their television remote adjusted for someone with no sight and get up at 7am not 8am. They said that generally staff were very good at enabling them to spend their day how they want telling them what the weather was and offering tea in bed. Comments by the people living at the Home about the quality of the food during this inspection were very positive, such as ‘excellent’ and ‘good’. One person confirmed that their specialist dietary needs were met and there were examples about how a gentle approach had been used to encourage people with improving their diet. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 16 We spoke with the Operations Manager who was very knowledgeable about providing the right kind of food for people living at the Home. There are regular discussions with people in residents’ meetings about what they would like to see on the menu and thought given to people with swallowing difficulties etc. The kitchen was well organised, clean and well staffed, with plenty of menu variety, choice and fresh produce. There is a large airy dining room and this is very well attended and a social event. Masonic events are also put on here from time to time. Staff were attentive during the meal and all people spoken to during the lunch period were more than happy with the meal arrangements. Tables are well dressed and there are plenty of condiments and a clear menu of what is offered at the time. People can enjoy celebration meals either in the dining room or as a private party with relations and friends. The Home can plan to have relatives for meals on any day. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to involve clients even more in menu choices, planning activities and outings. The Centre Court will be levelled and raised beds will be installed. People living at the home will be encouraged to tend the plants. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff, relatives and people living at the Home feel that any complaints would be dealt with appropriately although improvements could be made in record keeping. People are protected by staff that are able to recognise abuse and know their duty to report poor practice. EVIDENCE: Staff have a good knowledge about what ‘abuse’ is and what to do about it. The manager provides in-house training on the Protection of Vulnerable Adults, which all staff have attended. This is mandatory. One care plan had records of bruises on one person but these needed to be much more detailed in how they happened and how they are being monitored rather than just a date. Any restrictive measures that are used in a persons’ best interests such as bed rails should be discussed clearly with the person and/or representative and the multidisciplinary team. The Home had clearly thought carefully about how they care for people safely and there was a good care plan relating to minimising falls for one particular person living at the Home records need to reflect a wider decision making approach. Overall the Home ensures that people are well protected. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 18 All people spoken to felt that staff would listen to and act appropriately should they have any concerns. Everyone was very happy with the care that they received at the Home. One person said ‘I have no complaints, why should I?’ Others felt that they could tell the manager anything and had no concerns. Although the Home has a good complaints procedure and policy that is available to all, the records about any complaints are not very organised. It was difficult to see what was the concern and how and when it had been actioned as they are recorded on bits of paper within the incidence file. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to continue mandatory training, ensuring that staff have the right level of knowledge to recognise any form of abuse. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provides people living there with a clean, safe, comfortable and homely place to live. EVIDENCE: The Home is purpose built and very well maintained including the extensive gardens, which are easily accessible. There are 7 wings on 3 floors, 2 nursing designated staffed by Registered Nurses. Corridors are wide and the ground floor has access to pleasant patios. There are many communal areas, some for television watching and another for listening to music or being quiet. At present one area is being used by the Hospice Day Centre on a temporary basis but this does not impact on current residents of the Home. Hand washing facilities are available in the laundry area. Liquid soap, gloves and paper towels were seen in peoples’ rooms to help prevent cross infection. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 20 Staff are trained in infection control and there are clear policies. There were no offensive odours anywhere in the Home and a carer said that this was normal saying ‘there are no smells here’. Individual hoist slings were clean and well stored. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to complete the installation of a second lift to enable residents to move more easily from the front hall to the first floor. The enabling works have given the service an improved chemical store and an improved business office and Activities room. The Electrical System has been modernised throughout all the residents’ rooms. The Fire Prevention Survey has shown that more intumescent strips are needed on the fire doors and that there should be a better egress from the lower ground floor avoiding shallow steps. These are being addressed urgently and they will be in place by the Autumn 2008. The Home is planning Dementia Care unit, so that we can accommodate all the requests we have for this type of client. They are planning to improve the signage so that visitors can find Cadogan Court more easily. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deployment and numbers of staff available throughout the day and night are sufficient to meet the needs of the current residents. The procedures for the recruitment of staff are robust and offer full protection to people living at the Home. A full training programme ensures that staff are competent to meet the peoples’ needs. EVIDENCE: The Home has 7 permanent Registered General Nurses, 47 carers, 12 permanent night carers and a bank staff of 10. There is a Head of Maintenance and an assistant and an Operations Manager for the kitchen and domestic areas. Administration is done by a Business Co-ordinator and an administration assistant who are visible at the reception. All staff receive training that helps to meet peoples’ needs effectively and safely. For example, most staff have received training in Protection of Vulnerable Adults, continence, National Vocational Qualifications and many more, as well as health & safety training, fire awareness, food & hygiene and so on. This means that people benefit from a well-trained team of staff that are Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 22 able to meets their needs effectively. Staff also move around the wings including time on the nursing wing so that they can work with seniors and improve their knowledge. One staff member commented on how well the staff worked as a team. Staff said that they enjoyed working at the Home and that staff turnover was low. As the Home are planning a Dementia Care unit staff are being trained in this field, so that they can accommodate all the requests they have for this type of client. Staff hold a training passport, which they take to each training day. This also has information about their induction and mandatory training, which follows the recommended Skills for Care guidelines. Staff said that they felt well trained and supported. An agency staff member said ‘it’s lovely here, the staff work well as a team and know what they are doing’. One staff member was enjoying doing training on Control of Breathing and Relaxation. Training records are computerised and the manager can tell which staff are coming up to needing training. All people living in the Home who were spoken to praised the friendly staff saying that they were ‘nice girls’, ‘helpful and caring’ and there was a good rapport between staff and people living at the Home. Two people said that they sometimes had to wait 15 minutes for a call bell to be answered but this was not the general view and the staff rota indicated that staff numbers were appropriate. The deputy manager said that they would audit call bell times. Three staff personnel files were looked at and all included the required documents and checks to ensure that people living at the Home are protected by robust recruitment procedures. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to have RMBI staff and not agency staff and to enlarge the Care Staff Bank so that people living at the Home can be sure that staff knowledge of their needs remains consistent. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home is well managed, resulting in practices that generally promote and safeguard the health, safety and welfare of the residents. EVIDENCE: The Home has been well managed by the current manager who works hard and is very visible around the Home so say staff and people living there. They have recently decided to retire so the Home are advertising for a new manager. The Manager has allocated tasks and responsibilities to her Deputy, but has kept overall authority. The Deputy Home Manager has completed and passed the Internal Fast Track Management Scheme, which is commendable. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 24 An Acting Assistant Manager has been appointed who is a registered nurse and who has completed the RMBI fast track scheme, and is undertaking her Registered Managers Award training. All staff spoken to felt well supported by management. They were not happy about one aspect of staff deployment but this was an employment issue that the deputy manager was aware of and looking into. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Cadogan Court complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The Operations Manager said that complying with legislation was very important and was knowledgeable about their area. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. However, although there were good records of incidents in the Home such as falls and ‘wanderings’, this information was not always audited or acted upon appropriately as a whole to ensure that patterns in incidences are recognised promptly. This refers mainly to someone living with dementia and the Home have addressed the fact that this person needs re-assessing and that staff need further training on meeting these specialist needs. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. So that the risk of burning from hot surfaces is minimised, radiators within the home are covered or risk assessed. All windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows. So that the risk of burning from hot water is minimised temperature controls are fitted to bath taps. The Home did not keep Substances Hazardous to Health safely stored where people living in the Home could not have easy access, i.e. in various unlocked cupboards and the cleaning trolley was seen unattended at various times during the day. The Operations Manager said that they would immediately resolve this issue. The Home has a good security system including CCTV. This is solely trained on corridor areas and the screens are in the staff duty room. The Home has a comprehensive quality assurance system and the deputy manager was able to explain how quality assurance surveys are sent out annually and collated to find out peoples’ views on the service and act upon them. These can be anonymous if people wish. There are also regular residents’ meetings where people can raise any issues. Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 25 The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to extend the administraion office to provide more space and greater privacy, develop plans for the new Dementia Care unit and plan better access to the circular centre court area, which at present is a winding path amongst raised beds that is difficult for the less able to access. However, there are plenty of other places for people to go. Cadogan Court DS0000026703.V364916.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 Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 27 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 OP38 Regulation 13 4 (c) Requirement You must ensure that unnecessary risks to the health or safety of people living at the Home are identified and so far as possible eliminated. This refers to ensuring that all COSHH items are kept securely stored. Timescale for action 26/07/08 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 OP7 Good Practice Recommendations The Home should ensure that care plans contain clearer and more detailed information about peoples’ mental health care needs so that staff know how to meet these needs consistently and record care in an appropriate language. Any records relating to peoples’ bruising needs to be monitored and documented more clearly. The Home should ensure that the focus of the activity DS0000026703.V364916.R01.S.doc Version 5.2 Page 28 2. OP12 Cadogan Court programme should be on the individuals, to ensure that everyone living at the Home has an opportunity for appropriate, regular and meaningful occupation especially those who are less able to ensure their well being. 3. OP14 You should ensure that key workers communicate clearly to other staff any information about peoples’ choices so that these choices can be consistently respected. You should ensure that any records relating to complaints clearly show the details and how they were acted upon within the Home’s complaints policy and procedures. Any records relating to peoples’ bruising needs to be monitored and documented more clearly to ensure that they are fully protected. You should ensure that incident/accident information is thoroughly audited and any patterns identified to ensure that preventative measures and actions are implemented in a timely way. 4. OP16 5. OP18 6. OP38 Cadogan Court DS0000026703.V364916.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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