Inspection on 10/10/07 for Caradoc House

This inspection was carried out on 10th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Caradoc House 18/08/09

Caradoc House 25/09/08

Caradoc House 16/04/07

Caradoc House 29/11/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Caradoc House Ludlow Road Little Stretton Church Stretton Shropshire SY6 6RB Lead Inspector Rebecca Harrison Unannounced Inspection 10th October 2007 09:50 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 Caradoc House DS0000068051.V348340.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. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Caradoc House Address Ludlow Road Little Stretton Church Stretton Shropshire SY6 6RB 01206 241 085 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) Supercare (UK) Ltd vacant post Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None apply Date of last inspection 16th April 2007 – Key Inspection 20th June 2007- Random Pharmacy Inspection Brief Description of the Service: Caradoc House is a private care home registered with the Commission for Social Care Inspection to provide accommodation and personal care to a maximum of 14 people over the age of 65. At the time of the inspection nine people were accommodated. Mrs L. Thotapali is the Responsible Individual for the registered provider, Supercare Ltd and took over ownership of the home in September 2006. The home is actively seeking to recruit a new manager to put forward for registration. Ms Samstita Thota is currently the acting manager of the home. The home is situated in Little Stretton, one mile south of the Market town of Church Stretton. It stands in its own small grounds and provides ample car parking. Accommodation is provided over two floors and a chair lift and ramp is available to aid access. The home provides single bedrooms and one double bedroom, en-suite facilities are not provided. A communal lounge and separate dining room are located on the ground floor. The second floor of the building provides living accommodation for the owner. People who use the service and their representatives are able to gain information about this home from the Statement of Purpose, Service User Guide. Inspection reports about this service can be obtained direct from the provider or are available on our website at www.csci.org.uk The current fees charged are £365.00 per week for permanent residents and £390.00 per week for respite service. Additional charges are made for newspapers, toiletries, chiropody, dry cleaning and some activities. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 10th October 2007 by two inspectors over a period of eight and a half hours. Our pharmacist inspector undertook a full audit of the homes medicines management systems on 20th June 2007 and a report based on his findings was sent direct to the provider. A range of evidence was used to make judgements about this service to include a self-assessment completed by the provider and sent to CSCI, a tour of the home, discussions with service users, the staff, acting manager and responsible individual. Inspectors also looked at a number of records and observed aspects of care provided for two people using the service. As part of the inspection we received nine surveys from people who use the service, relatives and staff on duty and also spoke with health professionals and their comments are reflected throughout this report. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Older People and to review the 33 requirements made at the previous key and random inspections. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The home has a committed team of staff who work hard to meet the individual needs of the people in their care. We received three surveys from relatives and comments include: ‘Visitors are always made welcome at Caradoc. It is a small friendly home, that we would recommend to anyone’. ‘The home gives my mother the support and care she needs. She is very happy with all aspects of Caradoc House and so are her family. She is looked after in a warm and caring atmosphere, just like home from home’. ‘Now that Caradoc House has been taken over there have been considerable improvements, I can’t speak highly enough of the owners. From entering the front door there is now a feeling of warmth and caring and a very relaxed and cheerful staff. It is now a pleasure to visit my relative who seems a much more relaxed and happy man’. ‘Caradoc House provides a comfortable relaxed and informal environment’. I have no complaints. My mother is obviously very contented at the care home’ Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although significant improvements have been made the provider must work towards developing and implementing systems to address the shortfalls to include medication and staff recruitment procedures that potentially place people at risk of harm or abuse. Managers should attend training in safeguarding adult procedures and made fully aware of their responsibilities to ensure they are familiar with the process of recognising potential abuse and the formal referral process. Care plans although much improved, should link to initial needs assessments for continuity of care and be completed in partnership with service users and their representatives. Opportunities for daily life and social skills could be further developed. One person considered the home could improve by ‘Not having so much TV and perhaps a evening with the informal group to have a song, and play the piano, and more time spent talking to the residents’. The provider needs to seek an experienced manager to manage the service at the earliest opportunity in the best interests of service users. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 7 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. Caradoc House DS0000068051.V348340.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 Caradoc House DS0000068051.V348340.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): 1 and 3 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People are provided with information to decide whether this service will meet their needs and their needs are assessed prior to admission to the home. EVIDENCE: Following the last key inspection managers have reviewed and updated the Statement of Purpose and Service User Guide. Minor additions are required to ensure both documents reflect the service provided and meet the requirements of the Care Homes Regulations 2001, as amended. Each person has been provided with a copy of both documents as seen during a tour of the home. The admission procedure was discussed with the acting manager and responsible individual at length who demonstrated an understanding of the homes category of registration and the need to undertake or obtain comprehensive assessments of new people referred to the service. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 10 The files of three people were examined as part of this inspection and all contained a needs assessment completed by the home prior to admission, which evidenced service user involvement. Caradoc House DS0000068051.V348340.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 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The documentation and recording in care plans have improved which provides staff with the information they require to meet service users’ health and personal care needs. Procedures for the management of medication have improved however some practices have potentially placed people who use the service at risk of harm or abuse. Staff are sensitive to the individual needs of the people they support and ensure people’s privacy and dignity is upheld. EVIDENCE: Care records held on behalf of two people recently admitted were examined in addition to a care plan for an existing person to establish how care plans had improved since the last inspection. All three-care records were organised, easy to follow and contained the majority of the information required for the Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 12 delivery of care. Staff spoken with considered that information in care plans had improved which helps provide consistent care for the people they support. There was evidence that care plans had been generated from the needs assessments but not all plans had been developed or reviewed in partnership with the service user and their representative. The needs assessment for one individual indicated that the person requires assistance with personal care tasks and is diabetic however this was not reflected in the care plan. Managers committed to further developing care plans to ensure staff have detailed information for the delivery of care. Health care needs were identified on the three care records examined with the exception of one person being diabetic. Records evidenced that a healthcare professional had recently undertaken an assessment on one person due to their changing needs. Staff are responsible for maintaining a daily log on each individual with regard to their health and personal care. An assessment of risk for manual handling, falls and pressure sores are completed on admission and reviewed and these were available on the files examined. Our pharmacist inspector undertook a full audit of the homes medicines management systems on 20th June 2007. A number of shortfalls were identified in relation to recording, staff training and the storage of some medicines. Three requirements were made and a report sent direct to the provider. The management of medication was again reviewed as part of this inspection and although there was evidence that managers have made some improvements it was identified that one person had not been administered prescribed pain relief for three weeks. It was stated that ‘the home ran out of stocks’. It was reported that the home had telephoned the GP at the point of running out of stock, however managers were unable to evidence such. This is unacceptable practice and placed the person at risk of harm. Some discontinued medication was still being held in the new medication storage box however the acting manager committed to removing all discontinued medication immediately to eliminate risk of staff continuing to administer medication. The administration records continue to be confusing because the start date shown on the Medication Administration Charts was not the actual date that the cycle of medication was started, therefore this creates difficulty auditing records with medication held and managers were advised to seek advice from the dispensing pharmacist regarding this matter. It was reported that the next training course in the safe handling of medicines is to be delivered to four staff in November. Records seen during the inspection evidenced that some staff have already received training. Managers must ensure that training is effective and that a programme of monitoring staff’s Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 13 competence to administer people’s medication safely and effectively is initiated. How the service promotes privacy and dignity is clearly recorded in the homes Statement of Purpose. Staff were seen to knock on bedrooms doors during the inspection. Service users were very well presented and looked relaxed in the presence of staff. Surveys completed by service users and relatives indicate that staff are helpful. One survey stated ‘Staff have always shown great kindness and treat my mother with consideration and respect’. Caradoc House DS0000068051.V348340.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 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle and keep in contact with their family. Although improving further opportunities to meet peoples social, cultural and recreational needs should be explored. Menus provide variety taking into account special dietary needs and personal preferences. EVIDENCE: During the inspection one service user visited the pub using the ‘Ring and Ride’ service however no structured activity was seen offered. Throughout the day people spent time either in their own room or watching TV in the communal lounge. One person spoken with reported she prefers to spend time on her own and is afforded this choice. During a tour of the home one service user was seen visiting her friend in the room opposite. One survey received stated the home could improve by ‘Not having so much TV and perhaps an evening with the informal group to have a song, and play the piano, and more time spent talking to the residents’. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 15 Discussions held and surveys received clearly evidence that family and friends are welcome to visit the home. We received surveys from three relatives and friends and their comments very complimentary about the service provided. They indicated that the home always keeps in touch and that people are kept well informed of important issues affecting their relative and friends. People spoken with confirmed they are enabled to exercise choice and control wherever possible and that daily routines are flexible. Discussions with service users and surveys received evidence that people are happy with the meals provided although they were not aware of the main meal on the day of the inspection therefore managers were advised to improve the system of consultation. Menus seen offered variety and staff spoken with reported that they are aware of peoples personal preferences and alternative meals can be provided based on preferences and any special dietary requirements. Dietary advice has been obtained in relation to one person. Several invites to special celebrations were displayed on the notice board. Surveys received stated: ‘The home-cooked meals and menu choices is excellent’. ‘My relative was 95 recently and we were invited to his party where we met all the other residents and it made his day very special’. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives have access to a complaints procedure, which enables their views to be listened to. Managers require training in local safeguarding adult procedures to ensure they are familiar with the process of recognising potential abuse, the formal referral process and their responsibility of safeguarding people in their care. EVIDENCE: People have access to a complaints procedure, which is included in the Service User Guide and displayed in the home, next to visitors record. Discussions held with the service users and surveys received indicate that people have a clear understanding of what to do if they were unhappy with the service provided. Managers reported that since the last inspection one formal complaint has been received from a service user. This was seen on file and indicated that the complaint could potentially have been an adult protection issue that should have been referred under local safeguarding adult procedures. Managers reported that they had sought advice but not from the local authority or ourselves. No written outcome was provided to the complainant only a verbal response. The inspector later spoke with the complainant who reported that she had no further issues and was happy with the way the complaint had been addressed. She stated ‘things have improved under the new management’. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 17 Surveys received from two relatives state: ‘The complaint procedure was explained to the family and there has never been as issue’. ‘We have had no need to complain since takeover or to raise any concerns’. We have recently received a concern regarding this service about medication, staffing issues, pre-recruitment checks and the management of the home. We reviewed the concerns as part of our inspection and there was clear evidence that such concerns were substantiated and the outcome was shared with managers following our inspection. Since the last inspection two meetings have been held following a referral made under safeguarding adult procedures in relation to two people who no longer receive a service. The case has since closed. Managers confirmed that they had a copy of the local safeguarding adult procedures and had read this however following our findings it is recommended that managers attend training in the local policy and are made fully aware of their responsibilities. It was reported that some staff have had training in adult protection, which was confirmed by some staff spoken with. Managers stated that training is being arranged for new staff. Service users spoken with confirmed that they are satisfied with the service provision, and feel safe and supported. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The environment is much improved providing people with a clean, safe and comfortable place to live, which is appropriate to their needs. EVIDENCE: Caradoc House provides accommodation over two floors and a chair lift and ramp is available to aid access. All but one of the bedrooms are single, En-suite facilities are not provided. A lounge and dining room are available. People spoken with reported that they are happy living at the home which is well maintained and pleasantly decorated. Since the service was last inspected a number of improvements have been made and new equipment purchased. Such improvements include refurbishment of bathrooms, installation of thermostatic mixer valves, replacement of seven windows, a new industrial washing machine with sluice Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 19 facility, refurbishment of the freezer room, a new fridge, double oven, two beds, replacement boiler and stereo. One bedroom has been redecorated, new soft furnishings purchased and a new carpet fitted. People said that they are happy with their bedrooms, which were found personalised, clean and furnished to a satisfactory standard. A new domestic member of staff has been employed. Discussions held evidenced that she is very committed to her job and maintains good standards of hygiene. She demonstrated an understanding of substances hazardous to health and reported that she has read the data assessments. A new file has been developed since the last inspection containing data sheets for the products used and other useful information for staff. Infection control procedures are much improved with the purchase of liquid soap; paper towels and dispensers a sluice washing machine, coded mops and cleaning schedules. It was reported that some staff have completed training in infection control. The home was found clean and tidy during this unannounced inspection. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People who use the service are supported by a committed staff team however the homes continued poor recruitment procedures potentially place them at risk of harm or abuse. EVIDENCE: On arrival at the home there were three support staff on duty and a domestic member of staff. Eight service users were at the home prior to a further person being admitted late morning. Staffing levels have temporarily increased due to the needs of one person admitted for respite care. The home has experienced a high turnover of staff since the last inspection and reasons for this were shared with inspectors. The care team currently consists of an acting manager, assistant manager, four care staff and five new relief staff. Four permanent staff hold National Vocational Qualifications (NVQ) at level 2. An NVQ assessor visited the home during the inspection to meet with the owner who is currently undertaking the Registered Managers Award. The staffing rota examined was not an accurate reflection of staff on duty. Managers committed to reviewing this to ensure it is an accurate working tool and includes staff names in full, job title and contracted hours. Shift patterns have recently changed to avoid staff working long shifts however this has caused some conflict amongst staff as it appears not all staff were consulted with. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 21 Feedback received from surveys and discussions held suggest that staffing is sufficient to meet the individual needs of the people accommodated. We have received a concern regarding new staff whose first language is not English. Although people spoken with were very complimentary about the care provided this does present difficulty with communication, which was evidenced during the inspection. Concerns were also expressed about the amount of hours relief staff are working across this home and another local care home. People spoken with were very complimentary about the care provided which was also evidenced in the surveys that we received. Staff files for all new staff employed since the last inspection were reviewed. Files were very well presented however significant shortfalls were found. The required information to support a thorough and robust recruitment process was not available failing to protect the health and welfare of service users. Of the seven files examined only two contained written references. One was from a person not stated on the application form. There was clear evidence that staff had commenced direct work with service users based only on a check against the national list of people judged unsuitable to work with vulnerable adults. The majority of application forms were incomplete, position applied for not stated and not signed or dated by the applicant. There was no evidence that managers had questioned gaps in employment history and not all staff have received induction to the required specification. Requirements have been made at previous inspections of the home in relation to recruitment processes. Due to continued poor recruitment procedures adopted by the home inspectors issued an immediate requirement notice for the owner to take action to protect the health and welfare of service users. Managers have acted and told us what they are doing to improve. Staff training records and certificates of attendance were available on the files examined. Records seen indicate that staff have received some training in safe working practices and training appropriate to the client group they support. However an overall training matrix was not available which can provide a useful planning tool for managers as well as a record of the home’s position regarding training provision. Staff reported that training has improved but discussions indicated that not all staff have received training or updates in safe working practices, which managers committed to address. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 22 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, 36,37,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Managers have an understanding of the areas in which the service needs to improve to provide positive outcomes for people in their care. Although much improved some working practices do not fully promote the health, safety and welfare of service users and staff potentially placing people at risk. EVIDENCE: The previous acting manager has stepped down and is now assisting another member of staff to manage the home until a new manager is recruited. The new acting manager has commenced the Registered Managers Award. She has introduced a number of changes and working hard to improve overall Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 23 outcomes for service users but lacks experience of managing a residential service. Since the last inspection the owner has actively sought to recruit an experienced manager to put forward for registration however this has proved unsuccessful to date. Managers committed to keep this under review and to keep us informed on the situation. The owner and current acting manager have liaised with us concerning a number of matters and this inspection evidenced that a significant number of improvements have been made to benefit the people accommodated and appear committed to change. Discussions held and surveys received indicate that generally people are satisfied with the management of the home. Comments received include: ‘Management and care staff always have the residents welfare and best interests to heart at all times’. ‘I would like to see improved communication between management and staff and see more of managers on the shop floor’. The home has a quality assurance policy in place and since the last inspection surveys have been distributed to service users and comments include: ‘Staff are all very kind’ ‘More entertainment is needed’ ‘Staff are cheerful, polite and efficient’ The home provides lockable storage facilities for people to store their valuables and a policy on the management of service users finances is in place. A record of monies held is available however records should be individualised and care plans clearly indicate how finances are managed, which managers committed to reviewing. Evidence of formal staff supervision was available on some of the staff files examined and confirmed in surveys and discussions held with staff. Managers were advised to develop a supervision recording matrix to record to provide a quick overview to when staff receive formal supervision and to ensure staff receive this a minimum six times per year to discuss aspects of practice, career development needs and the philosophy of care. Although improved record keeping in the home is variable in quality so that service user’s rights and best interests are not always safeguarded for example medication records and staff records. One person stated, “Care plans are kept in the owners private flat which is locked when she is out”. This needs to be addressed, as records relating to service users must be accessible to staff at all times. We made a large number of requirements in relation to health and safety when we inspected the home in April 2007. Following the last inspection managers commissioned an external consultancy firm to review the homes health and safety management systems and a number of improvements have since been Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 24 made. Improvements include the fitting of thermostatic mixer valves, cleaning schedules, temperature monitoring records for testing of water, freezer, fridge and fire checks, lighting and a weekly health and safety audit of the home. Seven rotten windows have been replaced, policies and procedures updates and risk assessments for safe working practices developed however managers were requested to undertaken an assessment for one service user who uses the stair lift independently and for a person with a medical diagnosis and leaves accesses the community unsupported. Portable appliances have been tested and electrical hardwiring checks are due to be undertaken shortly. The storage of hazardous substances is much improved and a file for data sheets in place. Procedures for infection control are now in place. Managers reported that they have arranged an appointment with the fire officer to visit the home shortly to review the fire safety procedures and discuss the wooden fire escape recently installed. An audit of the homes accident records evidenced that there have been seven accidents relating to service users since the last inspection. Four of these accidents should have been reported to us under Regulation 37 of the Care Homes Regulations 2001. Managers were reminded of their responsibility concerning this and committed to report any further accident requiring notification. Discussions with staff indicated that they had received some training in safe working practices since the last inspection and some training certificates were available on the staff files examined but with the absence of a staff-training matrix it proved difficult to ascertain exactly who had attended what training. It was reported that the home has a first aider on duty at all times. Managers were advised to undertake a first aid risk assessment as required following recent guidance for care homes. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 25 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 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 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 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 3 3 2 Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Requirement Timescale for action 10/10/07 2. OP29 19(4, 5) Schedule 2 3. OP30 18(1)(a) (c) 4. OP38 37(1)(2) Medication must be readily available and given as prescribed to ensure peoples health needs are met and people are not placed at risk of harm or abuse. Recruitment procedures must 10/10/07 ensure that all pre employment screening has been carried out or service users may be at risk of harm or abuse. Previous timescale of 28/11/06 and 30/01/07 not met. Staff must not work 10/10/07 unsupervised until they have received sufficient training to deem them competent as they may compromise the safety of service users and themselves. Previous timescales of 28/11/06 and 30/01/07 not met. Notifications of death, illness and 10/10/07 other events must be reported to CSCI without delay to include medication errors to ensure peoples health and welfare is monitored. Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 27 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 OP1 Good Practice Recommendations Minor amendments should be made the Statement of Purpose and Service User Guide to ensure both documents are an accurate reflection of the service provided and meet the requirements of the Care Homes Regulations 2001, as amended A system to assess staff’s ongoing competency to administer medication for the protection of service users should be developed. Activities should be further developed in accordance with service users preferences, expectations and abilities. Managers should attend training in safeguarding adult procedures and made fully aware of their responsibilities to ensure they are familiar with the process of recognising potential abuse and the formal referral process. That an experienced manager is appointed at the earliest opportunity and an application for registration is submitted to CSCI. An assessment of risk for the person using the stair lift independently should be undertaken. 2. 3. 4. YA9 OP12 OP18 5. 6. YA31 YA38 Caradoc House DS0000068051.V348340.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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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