Inspection on 28/02/06 for Canadia

This inspection was carried out on 28th February 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 but made no statutory requirements on the home.

Other inspections for this house

Canadia 07/04/09

Canadia 30/05/08

Canadia 28/11/07

Canadia 31/05/07

Canadia 17/08/06

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Canadia 41 Pearson Park Hull East Yorkshire HU52TG Lead Inspector Kishon Dee Unannounced Inspection 28th February 2006 09:00 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 Canadia DS0000064770.V263884.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 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. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Canadia Address 41 Pearson Park Hull East Yorkshire HU52TG 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) 01482 802572 Mrs Heather Feeney Mrs Nicola Jayne Owens Mrs Margaret Lilian Norris Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Staffing must meet the levels set by the residential forum. The outstanding requirements must be met within four months of registration. The care home may provide care for 1 named service user with a MD To include one service user under 65 years of age. Date of last inspection Brief Description of the Service: Canadia is a three story semi-detached building situated in Pearson Park close to the centre of Hull. It is a period property and the front of the house still gives that impression. The home is on a bus route to the city centre and a short walk from Newland Avenue shopping area. Residents can access a small area to the front garden in warmer months and there is parking space to the side of this for two cars. Residential care only is provided, to a maximum of sixteen residents and mostly in double rooms; 7 of the 9 rooms are double accommodation. Only one bedroom has en-suite facilities of a toilet and a shower. Two lounges offer a pleasant environment in each, while the dining room is extremely small, resulting in some service users having to eat at tables in the lounges and others finding it difficult to get into their places at table. The laundry is sited in a wooden garage at the side of the house. The home is providing a service of care not only to older people, but also to one person with a hearing impairment, one person whose primary need is mental health and one person under the age of 65. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. The home was sold recently and the new owners are now registered with the CSCI. The inspection was carried out with the owners, residents, relatives and staff of Canadia and took 6 and a half hours to complete over one day. The inspection included a tour of the premises, examination of staff and residents files and records relating to the service. The inspector spoke to residents, the owners staff and one relative and their comments are included in this report. What the service does well: What has improved since the last inspection? What they could do better: Records and risk assessments are missing, incomplete or inaccurate. They are not reviewed on a regular basis and leave residents at risk. Staffing levels on a weekend are not always maintained. The assessment and admission procedures need to improve to ensure the home can meet potential residents identified needs. The training and supervision provided to staff needs to improve. Recruitment procedures are not robust enough to ensure the protection of residents. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 6 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. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 7 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 Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Progress is needed to improve the admission procedure to ensure that there is a proper assessment prior to people moving into the service. Without this there is no assurance that their needs will be met. EVIDENCE: The inspector looked at six files. Four of the residents had an individual plan of care, two new residents did not. There have been three recent admissions to the home and none of these admissions had all of the documentation required. The home had not obtained a copy of the care management assessment and care plan for two of the individuals and daily notes indicated that staff had to contact a relative for advice when one resident had a change in their health. The assessment and admission process is not adequate to provide residents with the assurance that the home can meet their identified needs and does not provide staff with sufficient information to ensure that new residents needs are met. These shortfalls could place residents at risk. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 8 & 9 & 10 Not all resident’s health, personal and social care needs are being fully met. These shortfalls have a potential to place residents at risk. EVIDENCE: Four of the six individuals had an individual plan of care. It was noted that the files have been organised since the last inspection with separate sections making the information easier to find. Two of the most recent admissions did not have a plan of care. One resident who had recently been admitted had a problem with his health and daily notes state that staff had to contact a relative for advice on what action needed to be taken. The staff are having difficulties with one resident’s mobility needs and the inspector noted that staff used a lifting technique which is no longer used. The sickness records also showed that a member of staff had injured her back when lifting the residents and had two weeks on sick. Inspection of this resident’s file that no amendments had been made to risk assessments to accommodate these changing needs. This resident is using the stair lift as her room is upstairs but there is no risk assessment completed to demonstrate that this is safe and the owner was asked to carry this out as a matter of urgency. There have also Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 10 been changes in the individuals health but risk assessments have not been updated. Inspection of the records indicates that the amount of information contained within the plan varies. Plans and risk assessments are not complete, up to date or maintained. Staff documentation of the daily care provided lacks detail and does not clearly show the actual care given. Discussion with the staff indicate that they have an understanding of the needs of the residents but this is on an informal verbal basis and the care plan lacked the guidance required. Residents are at risk of not having their health care needs met if these informal systems of communication break down. One resident currently self medicates. The home has adequate storage for medication. Inspection of the medication system indicated that the records where accurate and up to date regarding medication received, administered and leaving the home. All residents said that they feel that staff treat them with respect and that their right to privacy is upheld. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 13 & 14 & 15 Residents are provided with limited opportunities to participate in social activities. Residents maintain contact with family friends as they wish. EVIDENCE: Activities and social needs where discussed with four residents and all said this is an area that the home do not do well. Two residents said that the home used to have outside entertainment coming into the home but this has not happened for some time. There is no activities programme within the home and activity sheets within residents files have TV or listening to music for the majority of activities. All residents spoken to said there time for getting up in a morning was early commencing at five O clock. No one said they got up after seven and breakfast is completed before eight. Although all residents said they were satisfied with their designated time for getting up the preferred time for getting up should be recorded at the point of admission. One resident said that he had made a decision not to share his room when it became vacant and the new owners had respected this decision and moved the second bed out, this has improved the quality of his life. Meal and menus remain unchanged for the main course. Two residents said that the tea time meals have improved in terms of choice and that staff now come round on an afternoon and have several options for people to choose Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 12 from. Three residents commented that the main meal provision and beverages are not quite as good as it was at the previous inspection. The only change the inspector could find was that the ingredients are been purchased from other providers and this should be discussed with residents. The only milk at the home was long life skimmed milk and again this should be discussed with residents to ensure this is what they prefer. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has a satisfactory complaints procedure. The policies and practices regarding restraint and challenging behaviour are inadequate and do not protect vulnerable people. EVIDENCE: The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. The homes policy on aggression and restraint states that when an incident of aggression occurs an incident form must be completed. This does not happen. This was discussed with the owner who said that their policy was one of no restraint and the policy would be re-written. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 22 & 23 & 24 & 26 The environment does not provide residents with a safe and well maintained environment. EVIDENCE: There have been improvements to the decoration in the home since the last inspection. The inspector looked at all of the environment and the home requires work in the majority of areas. A number of carpets are worn and stained and require replacement. Some of the furniture in the bedrooms is looking worn and has broken handles and trims. Furnishings are not provided as required and none of the service users spoken to had been asked about what furnishings they want. The new owners are working at addressing these requirements it will take some time to achieve as there is so much work required. Service users confirmed that they are able to bring their own belongings into the home and furnish their room with them. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 15 One resident has had a stroke and is using the stair lift to access her room which is on the first floor. There is no risk assessment about this and this needs to be done to ensure that a stair lift is safe. The home does not currently have a hoist and the care staff are struggling to meet the needs of some residents. The new owners are looking into purchasing a hoist and a company brought one on the day of the inspection for them to try. The layout of the building may still cause some problems and these need to be addressed. If the home cannot meet the moving and handling needs of people then they must review the appropriateness of the placement. The new owners have employed two domestic staff and this has resulted in the more thorough cleaning of the home. During the environmental inspection the home was found to be clean and free from malodours. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 28 & 29 & 30 Staff are not deployed in sufficient numbers to meet the needs of service users. Staff members have not received all of the mandatory training and as a result staff do not have the necessary skills; this could put the residents’ health and safety at risk. EVIDENCE: The home are not keeping rotas and this must be developed. The layout of the home over three floors could cause some difficulties in the deployment of staff. Inspection of the current rota indicates that the home are maintaining three members of staff during the day on weekdays but this is not always been maintained on a weekend. The home must maintain the agreed staffing levels at all times. Two service users commented on how good the staff are. The home has an experienced and enthusiastic team of staff who work well together. The staff are motivated and keen to ensure that residents receive a good standard of care. Three files were requested but only one could be produced. This indicates that although the home are carrying out some of the recruitment checks required they are not robust enough and need to improve. Inspection of staff files and discussions with three staff indicate that not all staff have had all of the mandatory training. The new owners are aware of these shortfalls and are currently putting a training plan together. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 17 Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 33 & 35 & 36 & 38 The acting manager has identified the areas which require improvement. There are still some practices that do not promote and safeguard the health safety and welfare of the people using the service. EVIDENCE: The home has recently been taken over and the registered manager has been absent from the home for some time. One of the owners is currently managing the home and has a good understanding of the areas that need to improve. Prior to the change in ownership the home had many requirements and the majority of these had been outstanding for some time. It is going to take some time to meet all of the requirements Service users, visitors and staff gave positive accounts of the home however there were many examples of poor communication, staff been unclear as to what was expected of them and practice been inconsistent between shifts. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 19 Staff do not receive supervision on a regular basis nor are their training needs reviewed on a regular basis. Some of the policies and procedures require updating or replacing. Discussion with two members of staff and inspection of the staff training log indicate that a large number of staff require one or more of the mandatory training courses providing or renewing. Risk assessments are missing or require updating. Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 20 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 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 x x 1 2 2 x 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 2 x 1 Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14 Timescale for action The Provider must ensure it 30/04/06 obtains a copy of the care management assessment and care plan and that service users needs are fully assessed and recorded. The home must complete the documentation it intends to use. A service user plan of care must 30/04/06 be produced for each service user, with their consultation. The registered person must ensure that risk assessments are completed. All individual plans and risk assessments must be reviewed monthly. The registered person must 30/04/06 ensure that healthcare needs are met and assessed. The registered person must 14/04/06 ensure that service users choices about their daily routine are documented within the individuals plan of care. Times for getting up must be flexible. The registered person consults 21/04/06 service users about their social interests, and makes arrangements to enable them to DS0000064770.V263884.R01.S.doc Version 5.1 Page 22 Requirement 2 OP7 4 3 4 OP8 OP12 12, 13 12 5 OP12 12 Canadia 6 7 OP18 OP19 8 OP22 9 OP23 10 OP24 11 OP27 12 13 Canadia OP38OP30 OP28 OP29 engage in local, social and community activities. 12, 17, 18 The registered person must review the homes current policy on restraint. 23 The registered person must ensure that a programme of routine maintenance and renewal is devised and implemented. 23 The registered person must ensure that if provides equipment to meet the needs of the residents. 23 For those rooms with less than 16sq metres usable floor space (excluding en suite) the registered person must clearly demonstrate:1. What compensatory communal space arrangements there are in the home?2. How the bedrooms meet service user needs and lifestyles.3. That service users have been made aware of the required minimum double room size. 4. And that each service user has made a positive choice to share their room. 5. This requirement does not necessarily waive the requirement for double rooms to have at least 16sq metres of usable floor space but the information will be taken into account when making a decision. 23 Provider must ensure the service users have equipment listed in standard 24.2, worn and broken furnishings must be replaced. 18 Staffing levels must meet the residentail staffing forum and be maibntained at that level at all times. 18, 19 The registered person must ensure that all staff are trained and competent to do their jobs. 18 The registered manager must DS0000064770.V263884.R01.S.doc 30/04/06 30/05/06 07/04/06 30/05/06 30/06/06 14/04/06 30/04/06 30/04/06 Page 23 Version 5.1 14 15 OP31 OP33 8, 18 33 16 OP36 18 17 OP38 18 devise policies and procedures for the recruitment of staff. All checks must be carried out prior to any staff commencing work. The registered person must ensure that the home has a manager. The registered person must ensure that the home has a satisfactory quality assurance process the results of which must be published and distributes to stakeholders and the CSCI. The registered person must ensure that staff receive supervision on a regular basis which includes all of the areas specified in 36.3 of this standard. The registered provider must ensure that all staff receive mandatory training. Risk assessments must be completed and reviewed on a regular basis. 30/05/06 30/06/06 30/06/06 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Canadia DS0000064770.V263884.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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