Inspection on 16/04/07 for Caradoc House

This inspection was carried out on 16th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 10/10/07

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 Key Unannounced Inspection 16th April 2007 09:35 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.V335025.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.V335025.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.V335025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2006 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 eight people were living at the home. Mrs L. Thotapali is the Responsible Individual for the company named Supercare Ltd and took over ownership of the home in September 2006. The Acting manager is Mr A Mason. An application for registration of a manager has yet to be undertaken. 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 provided to assist access. All but one bedroom are for single occupancy, ensuite 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 registered provider and sleep in facilities for staff. People who use the service and their representatives are able to gain information about this home from the Statement of Purpose, Service User Guide and inspection reports produced by Commission for Social Care Inspection. Inspection reports can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk The current fees charged vary between £365.00 and £385.00 per week depending on the care, support and accommodation required. There are additional charges for newspapers, toiletries, chiropody, dry cleaning and some activities. Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 09.35 a.m. and was carried out by two inspectors over a period of eight hours. The inspection included observation of care experienced by people using the service, talking with staff, the registered provider and acting manager, looking in detail at all aspects of care for two people, observing work practices, examining a number of records and a tour of the home. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Older People and to review progress made by the home since the last inspection undertaken on 29th November 2006 when thirty-nine requirements were made. 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. All staff, managers and service users were very helpful and co-operated fully throughout the inspection process. What the service does well: What has improved since the last inspection? Some improvements to the environment have been made to provide a more homely place for people to live to include redecoration of a number of areas and the majority of radiators have now been fitted with guards to safeguard people. Staff reported that improvements have been made under the new management and that the team is friendly, efficient and supportive of one another. Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 6 Contracts of terms and conditions of residency between the provider and the individuals living at the home have been developed and all service users have been issued with a Statement of Purpose and Service User Guide. New assessment and care planning recording tools have been developed however these require additional work. Following a number of falls resulting in injuries to service users and a referral made by CSCI under local adult protection procedures, waking night cover has been introduced from 1st April 2007. This provides a service to the people who require their care needs attended to throughout the night and has been welcomed by both service users and the staff team. What they could do better: The registered person and acting manager appear committed to providing a quality service for the people in their care however the findings of this inspection clearly evidence that the home is lacking management and leadership. Many of the requirements relating to the health, safety and welfare of service users and staff remain outstanding therefore urgent action must be taken by the registered provider to address the shortfalls identified to improve overall outcomes for the people living at the home. Although staff on duty had a good understanding of peoples support needs, care plans and risk assessments need to be improved to ensure that all staff are provided with up to date information to meet the individual needs of the people accommodated. An ‘Immediate Requirement’ notice was issued at the time of the inspection in relation to risk management to ensure the safety of service users. The provider was required to take remedial action for these matters within 48 hours of the inspection and an action plan to address such issues was forwarded to CSCI within the stated timescale. The homes admissions procedure needs to be reviewed. People must only be admitted to the home following a comprehensive assessment of need and admissions must be in line with the homes category of registration. Medication procedures and practices require further development to safeguard service users. A number of requirements have been brought forward from the previous inspection. The responsible person was not able to evidence compliance due to the poor record keeping systems currently in place. Please contact the provider for advice of actions taken in response to this Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 7 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.V335025.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.V335025.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): 1,2,3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives are not provided with accurate information about what the service offers to make an informed choice whether the home is suitable to meet their needs. People using the service are provided with a contract of their terms and conditions of residency. There is no clear or consistent assessment process in place to adequately inform the care planning process and provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: Following the previous inspection the provider had reviewed the Statement of Purpose and Service User Guide and people who use the service have since been provided with a copy of these documents. Service users rights to Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 10 respect, dignity, equality and opportunity are included in the philosophy of the home and included in the homes Statement of Purpose. The findings of this inspection and examination of these documents evidence that they are not an accurate reflection of the service currently provided. Information in relation to the regulatory body was outdated and the criteria stated for admission and assessment is not in line with the homes category of registration. This was also evidenced through an assessment obtained on a prospective self-funding service user who was due to be admitted to the home the following day of the inspection. The assessment indicated that the person had a clinical diagnosis of dementia, for which the home is not registered. The proprietor stated during the feedback session following the inspection that the prospective service user would not move in until a proper assessment of need had been undertaken. A Preliminary assessment was seen on the file of the person most recently admitted to the home who is self-funding. The assessment contained minimal information, for example ‘needs assistance with bathing’ and was not dated or signed by the person who undertook the assessment. The person most recently admitted to the home reported that a relative visited the home prior to her being admitted and stated that she had very comfortably settled and that the staff are very kind. Since the last inspection a contracts of terms and conditions of residency between ‘Supercare Ltd’ and the individuals living at the home have been developed and these were seen on the service users files examined and were signed and dated by the provider, service user and their representative. It was reported that intermediate care is not provided therefore it was not possible to assess Key standard 6. Caradoc House DS0000068051.V335025.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 poor. This judgement has been made using available evidence including a visit to this service. The care planning system is in a format that does not provide staff with the information they need to satisfactorily meet all service users health and personal care needs potentially placing service users at risk. Systems for the management of medication are not sufficiently developed and potentially put service users at risk. People who use the service are treated with respect and dignity. EVIDENCE: Two service user files were examined as part of the case tracking process and contained individual care plans reviewed in March 2007. A new care planning format has been introduced since the last inspection however the forms are tick lists with additional comments to include ‘needs assistance’. There was no evidence that service users have contributed to the development of their care plan and this was confirmed through discussions held with two people during Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 12 the inspection. Some of the detail in the plans was inaccurate or out of date. Some care practices detailed were inappropriate although, when questioned, staff demonstrated that they did not follow the identified procedures. Record sheets were available to evidence visits from health care professionals although the GP had two sheets which contained contradicting information. Daily records are maintained and these were seen to contain staff comments include ‘All care given’, ‘Nothing to report, all is well’. ‘No problems’. Risk assessments on service users files were generic and inappropriate to support individual plans and daily activities. Likewise risk assessments to support manual handling tasks did not contain sufficient detail to demonstrate safe working practices in that area and one was incomplete. Two risk assessments for falls were seen on one file and contained conflicting information, were not dated or signed. The physiotherapist on duty at the time of the inspection supported this finding and offered support to review them. The use of ‘acute care plans’ during episodes of ill health reflected that increased monitoring and support is implemented. However the night care plan for the same service user had not been completed. Weight charts were not always up to date and nutritional screening forms seen were blank on one service user file and incomplete on another. There was additional evidence that concerns in relation to health care needs are not always followed up with the General Practitioner for example daily records seen for one person indicated that the person complained about having a bad back during the night but this had not been followed up by the day staff. Likes and dislikes were recorded on both files reviewed and daily records reflected that the one service user case tracked by the inspectors visited a local day centre on a regular basis, had her hair done and received visitors. The service user was out at the time of the inspection at the identified day service. Two service users spoken with considered their privacy and dignity is upheld and that staff knock on their door prior to entry. Service users present during the inspection appeared well groomed and staff on duty were observed to treat people with respect. As waking night support has recently been implemented within the home service users have been asked to ‘consent’ to being checked however the consent forms were not dated. There is also an option for them not to receive this service if they prefer. One person case tracked used to self administer their medication prior to moving into the home and the record seen on file stated ‘Is able to do own medication but agreed that staff can administer’. This clearly evidenced that service users are not encouraged to keep and administer their own medication based on a risk assessment. The Medication Administration Record for one individual had been signed a week in advance from 16.4.07 to 23.4.07. Staff were unable to ascertain the reason for this practice, although stated it was an Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 13 error. An incorrect ‘code’ used for recording when one service user had not been administered medication was seen on the medication administration record and no reason stated. Numerous boxes of prescribed medication pertaining to two deceased service users were found in the refrigerator in the main kitchen in the same container used to store milk, salad cream and sauces. The provider committed to ensure such medication is returned to the pharmacist at the earliest opportunity. At times the kitchen was left unsupervised and the refrigerator easily accessible presenting a security risk. Eye drops were found opened and not dated. Unlabelled ointments and a box of homely remedies were stored in the newly purchased medication cabinet although the provider stated that homely remedies are only administered following the advice of the GP and consent of service user. The latest staff member to join team on 01.04.07 had undertaken medication training through a previous employer. A medication-training certificate was seen on the acting managers personnel file, dated 2000 again from a previous employer. There was no evidence of medication training being organised by the home. The proprietor stated that the local pharmacist has been to the home to review medication arrangements and is currently writing a policy to support practice. Caradoc House DS0000068051.V335025.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 however opportunities to develop their social, cultural and recreational needs could be further developed in order to meet their expectations. EVIDENCE: Discussions held and records examined indicate that activities could be further developed. Aims and objectives seen on one service user file examined stated ‘To encourage her to join in activities’ however the only activity observed was a short sing along session held in the afternoon. One person stated ‘I just do my own thing and stay in my room’. The home does not employ an activity worker however an activity record is held and this was examined. Records indicate that three people access a day service on allocated days during the week, other activities recorded included cards, ludo, gardening, reading, colouring in, church, watched a film, sat outside and ‘had new glasses fitted’. The acting manager acknowledged the need to provide greater opportunities and is looking to address this. Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 15 Two service users spoken with reported they regularly see their visitors and this can be accommodated in the privacy of their room or in the communal rooms provided and that their relatives are always made welcome. Contact with family and friends was seen on the daily records of the files examined. Both people spoke with considered that they are enabled to exercise choice and control over their lives. Service users spoken with reported they were happy with the food the home provides and alternative food is made available. A six-week rolling menu is in place and this appeared varied and balanced. It was reported that none of the current people accommodated have any special dietary needs. Personal preferences in relation to their diet were available on the files examined. A number of items in the fridge and cupboards were found unlabeled. There was no fresh fruit available and the food store cupboard contained inedible broccoli. A cook is not employed therefore support staff are expected to prepare and cook all meals in addition to washing up. This therefore takes them away from their support roles and given the current staffing levels this should be reviewed. Caradoc House DS0000068051.V335025.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. Service Users have access to a complaints procedure that enables them and their representatives’ views to be listened to and acted upon. Lack of staff training in adult protection and inadequate recruitment practices potentially places service users at risk. EVIDENCE: Ms Thotapali stated that there had been no complaints received at the home since the last inspection undertaken in November 2006 and no complaints were seen recorded in the complaints book held. The complaints procedure was seen displayed and a copy included in the Statement of Purpose and Service user Guide. A service user spoken with had a clear understanding of who to approach if he was unhappy with the service provided. All staff were aware of the procedure for sharing concerns. There was no adult protection policy seen and the acting manager referred only to the local adult protection referral procedures. Concerns that the home was accommodating service users whose needs required night time care were raised at previous inspections and during a meeting held on 19/12/06, CSCI were assured all service users had been independently assessed by a qualified nurse to confirm that they did not require night time care or monitoring. Two Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 17 concerns were received by CSCI in February 2007 regarding injuries sustained by two service users following falls during the night therefore CSCI made a referral to the local team under adult protection procedures and meetings are currently ongoing. Following this waking night cover has since been provided from 1.4.07. There was no evidence that staff have attended Protection of Vulnerable Adult (POVA) or adult protection training and there was no specific adult protection policy in place only the multi agency guidelines – ‘Making a referral’ were seen. Caradoc House DS0000068051.V335025.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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with a clean and comfortable place to live. EVIDENCE: A full tour of the home was undertaken. Accommodation is provided over two floors and a chair lift and ramp is provided to assist access. Bedrooms with the exception of one are for single occupancy, en-suite facilities are not provided. Bedrooms in use were found personalised and discussions held with two people indicated that they were happy with the accommodation provided. A communal lounge and separate dining room is provided. The damaged glazing which was expected to be replaced before Christmas remains outstanding however reasons for this were shared with inspectors and the provider committed to give this priority in addition to the small number of radiators that have yet to fitted with guards. Many environmental Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 19 improvements have been made under the new provider and Ms Thotapali agreed to record these in a programme of maintenance and renewal. Two domestic staff are employed and the cleanliness of the home was generally satisfactory at the time of the inspection with the exception of the freezer and fridge appliances stored externally which were found dirty and a slight unpleasant odour was detected in one bedroom. Systems to control the spread of infection require review for example liquid soap was not available in all communal bathrooms and toilets and unnamed bathmats in need of replacement were found. Paper hand towels were not available and is was evident that concerns raised at the previous inspection had failed to be addressed. Caradoc House DS0000068051.V335025.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. Service users value the support that they receive from the staff team however unsafe recruitment processes are putting them at risk of harm or abuse. Staff working without full and adequate training and induction may further compromise the safety of people living at the home. EVIDENCE: Staff who spoke with the inspector stated that there was a ‘good atmosphere’ at the home and they were all very happy working there. They were able to identify recent improvements to the standard of the environment and the support they receive. Staff felt that staffing levels were currently adequate for the number of service users living at the home (eight) and they welcomed the introduction of a waking night staff member. Service users spoken with were positive about the staff team and commented ‘Staff are very nice here, they are kind’. The proprietor has started the process of staff appraisals and is then planning to implement regular formal supervisions. The proprietor also stated that she is currently looking into accessing mandatory training for all staff and on the day of the inspection one worker Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 21 was attending day 2 of her induction. Records available at the time of the inspection could not support that all staff have been appropriately trained however discussions with staff and the proprietor suggested that training opportunities are an area where the home is making improvements. Dates for future training courses were recorded. Waking night carers work unsupervised at Caradoc House although the proprietor and the physiotherapist are on site in their flat. One waking night carer has not yet completed her induction but is taking responsibility for the home. Four staff files were reviewed as part of the inspection. All files were well set out and were being stored securely within the home. Upon review it was found that not all required information was available to support a thorough and robust recruitment process. References were missing from all four files and an application form was seen on only two. It was of concern that the proprietor was unaware of information recorded on one CRB reviewed. One file reviewed was that of a volunteer. Requirements have been made at previous inspections of the home in relation to recruitment processes. The rota reflected staff on duty on the day of the inspection and demonstrated that there are two staff on duty at all times. Caradoc House DS0000068051.V335025.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): 31,33,35,37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Current management arrangements are unsafe and inadequate. The proprietors and the manager’s lack of time and knowledge in relation to a range of administrative issues are leaving service users potentially at risk of neglect or harm. Records and policies are not being adequately maintained making it unclear if essential safety information is being shared and checked. This is placing service users and staff at risk in the event of a fire or any other emergency situation. EVIDENCE: Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 23 The acting manager works three days a week in his management role and two as a carer. He has over thirty years experience of supporting older people in care settings. He is currently working towards the Registered Managers Award and NVQ level 4 in Care and has recently attended first aid and fire safety training. He confirmed that he has not received a recent formal supervision with the proprietor, although it was clear that he had discussed areas of the role that he will and will not undertake. It was established at the time of the inspection that the acting manager is to apply for registration with CSCI. He identified aims and goals for the service and stated that he has reviewed care plans, with the exception of one. He acknowledged failings in relation to the content of the care files and spoke of how he wants to involve workers to improve them. In discussions with the inspector the acting manager agreed that he did not have sufficient time with current arrangements to carry out all managerial tasks required of him and the outcome of this inspection suggests that this issue needs to be addressed as an immediate concern. It was also identified however that both the proprietor and the manager do not have the skills to action some of the requirements made as a result of this inspection. The most worrying examples of the lack of effective management at the home involve the admission of a woman without proper assessment and the lack of appropriate risk assessments to support practices. Financial details were available on two files examined but lacked detail and the two service users spoken with stated that their families deal with their finances and that they are happy with these arrangements. One person showed the inspector the safe in her room for the safekeeping of her valuables. Policies and procedures are in need of review. Some policies still refer to the previous proprietor. The home did not have an adult protection policy although the multi agency ‘making a referral’ guidance was available. The Statement of Purpose and the policy to support quality management referred to the National Care Standards Commission. In relation to health and safety arrangements at the home records did not accurately reflect that relevant safety checks and assessments are being made. Staff were aware of good practice in relation to health and safety and infection control although findings at the time of the inspection suggest otherwise, for example infection control procedures. The fire alarm testing book was seen to reflect that checks take place although not weekly as required. The fire risk assessment document had previously been seen by CSCI although it was difficult to identify which was the most up to date copy. Records evidence that the home had not complied with the requirements made by the Fire Officer following his visit on 13.12.06 for example the requirement made for staff to receive training in fire safety. Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 24 The proprietor committed to go back to the fire officer to seek advice in relation to compliance in other areas. Accident records are now data protection compliant however the provider had to be advised how these should be stored. Twenty-six accidents were recorded since the last inspection with many accidents at differing times and not witnessed indicating a lack of supervision. CSCI have not received notification of all accidents and events as required under Regulation 37. Random testing of hot water outlets in service user bedrooms exceeded 50° and the temperature of bathwater in one bathroom was 46°C. This was also identified at the previous inspection. Bath water temperature charts were seen and recorded temperature did not exceed the recommended guidance. It was difficult to find all required information however there was evidence that the home has a contract with a leading gas supplier for maintenance of gas powered systems. The servicing agreements for servicing emergency lights and fire alarms was in a folder but not been signed or dated by the proprietor. Due to issues identified in this and other outcome groups it cannot be adequately demonstrated that the home is being run in the best interests of service users however the proprietor, the manager and staff all demonstrated a commitment to improving the service within their capabilities and seek outside input in areas where knowledge gaps have been identified. Caradoc House DS0000068051.V335025.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 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 Score 2 3 1 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 1 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 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x 3 x 1 1 Caradoc House DS0000068051.V335025.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 OP1 Regulation 4,5,6 Requirement Timescale for action 14/05/07 2. OP3 14 (1) (2) 3. OP7 15(1) 4. OP8 12(1)(b) 15(1 The Statement of Purpose and Service User Guide must be an accurate reflection of the service provided to ensure people can make an informed choice whether the home is suitable to meet their needs. New service users must only be 16/04/07 admitted in line with the homes category of registration and following a full needs assessment undertaken by a suitably qualified or trained person to ensure the home is able to meet the needs of the individual. Care plans must be developed 14/05/07 based on a comprehensive needs assessment and be an accurate reflection of the care provided and must be reviewed to ensure that information suggesting unsafe practices are removed. Previous timescales of 28/10/06 and 30/01/07 not fully met. Care plans must show details 14/05/07 that all resident’s health care needs are met as they should be, following any health care DS0000068051.V335025.R01.S.doc Version 5.2 Caradoc House Page 27 5. OP8 12(1) 13(5) 6. OP9 13(2) 7. OP9 13(2) 8. OP18 13 (6) 9. 10. OP26 OP27 13 (3) 18(1) professional advice at the time it is given, as peoples needs change. Previous timescales of 28/11/0,28/02/07 not met Detailed moving and handling and falls assessments must be developed, reviewed and updated at least once a month and also when significant changes/events occur. All staff responsible for administering medicines must receive training from an accredited external organisation. The system for storing and recording medication and assessment of staff’s ongoing competency to administer medication for the protection of service users must be reviewed The Responsible Individual must ensure all evidence is recorded in staff and service user records to ensure appropriate actions have been carried out to maximise safety and well being of service users. This includes recordkeeping for care and accident management, to make sure if peoples needs cannot be met at the home appropriate action is taken for this to be considered elsewhere. Robust environmental risk assessment, staff induction and health and safety training must be implemented. Previous timescales of 28/10/06 and 30/01/07 not fully met. Infection control procedures must be reviewed. The responsible individual must ensure suitably qualified, competent and experienced staff are employed in sufficient DS0000068051.V335025.R01.S.doc 14/05/07 30/06/07 01/05/07 14/05/07 14/05/07 14/05/07 Caradoc House Version 5.2 Page 28 11. OP29 19(4, 5) Schedule 2 numbers to meet the needs and safeguard the health and welfare of service users based on a comprehensive risk assessment. Previous timescales of 28/10/06 and 30/01/07 not fully met. Recruitment procedures must 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 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. The acting manager must be fit to carry out the manager’s role and an application to register a manager must be made to the Commission for Social Care Inspection. The proprietor must ensure that she appoints a competent and suitably trained person to carry out admission and risk assessments otherwise service users and staff will be placed at risk of harm or neglect. The responsible individual must provide evidence of a system to evaluate, improve, and maintain the service to show efforts made to safeguard and promote the well being of the people living at Caradoc House. Previous timescales of DS0000068051.V335025.R01.S.doc 14/05/07 12. OP30 18(1)(a) (c ) 14/05/07 13. OP31 9(1) 31/05/07 14. OP31 14 (1)(a) 14/05/07 15. OP33 24 31/05/07 Caradoc House Version 5.2 Page 29 28/10/06 and 30/01/07 not met. 16. OP36 18(2) The Responsible individual must make arrangements for suitable supervision of all staff, including the acting manager. Previous timescale of 28/02/07 not fully met. Policies and procedures must be reviewed to ensure they are current and accurately reflect the service provided at Caradoc House to ensure staff work safely and consistently. The quality of record keeping must be improved to ensure that information required by regulation is accessible, accurately reflects individual needs and that all managerial tasks are carried out as required. Checks to ensure the safe working of fire alarms and emergency lighting must be made as required ensuring that they would be in good working order in an emergency situation. Previous timescale 30/01/07 not met. The registered person shall ensure that risk assessments are carried out for all safe working practices including the use of all equipment used by service users. Previous timescales of 28/11/06 and 30/01/07 not met. The home accident/ incident recording system must realistically reflect all accidents/incidents which affect service user well being, and must show effective remedial actions are carried out to maximise resident safety. Previous timescales of 28/11/06 and 30/01/07 not DS0000068051.V335025.R01.S.doc 31/05/07 17. OP37 17(2) 01/06/07 18. OP37 17 14/05/07 19. OP38 13(4) 30/04/07 20. OP38 13(4) 14/05/07 21. OP38 13 (4) (c) 07/05/07 Caradoc House Version 5.2 Page 30 fully met. 25. OP38 13 (4) Comprehensive environmental risk assessments incorporating the homes responsibility to relevant health and safety legislation including, Legionella must be developed and implemented. Previous timescale of 30/01/07 not met. The home fire safety records must show evidence that the newly installed wooden fire escape meets the approval of the local fire officer Previous timescales of 28/11/06 and 30/01/07 not met. A detailed fire risk assessment must be carried out by an appropriately qualified competent person in line with the fire safety regulations. Previous timescale of 30/01/07 not fully met. The registered person must ensure appropriate servicing and maintenance of all essential services and equipment in line with necessary health and safety legislation, including portable appliance testing and 5 yearly electrical wiring installation checks. Previous timescale of 30/01/07 not fully met. The temperature of the hot water supply to areas of the home accessed by service users must not exceed 43 degrees Centigrade. Previous requirement of 2/12/06 not met. All substances hazardous to health must be securely stored to safeguard service users. All staff must receive urgent fire safety training including written DS0000068051.V335025.R01.S.doc 14/05/07 26. OP38 23(4)(b) 14/05/07 27. OP38 23 (4)(a) 14/05/07 28. OP38 13 (4) 31/05/07 20 OP38 13 (4) (a) 30/04/07 29. 30. YA38 OP38 13(4)(a) 18(1) 30/04/07 30/05/07 Page 31 Caradoc House Version 5.2 instructions in order to reinforce their responsibilities and what to do in the case of fire. Previous timescale of 02/12/06 not met. 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 OP12 Good Practice Recommendations It is strongly recommended that activities be further developed in accordance with service users preferences, expectations and abilities. Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 32 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. Extracts may not be used or reproduced without the express permission of CSCI Caradoc House DS0000068051.V335025.R01.S.doc Version 5.2 Page 33 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!