Inspection on 03/10/07 for Cascade Care Ltd (Cascade 1)

This inspection was carried out on 3rd October 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cascade Care Ltd (Cascade 1) 28/07/06

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Cascade Care Ltd (Cascade 1) 16 Bergholt Crescent London N16 5JE Lead Inspector Robert Sobotka Unannounced Inspection 3rd October 2007 09:55 Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cascade Care Ltd (Cascade 1) Address 16 Bergholt Crescent London N16 5JE 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) 020 8802 7167 020 8211 7791 enquiries@cascade-care.co.uk Cascade Care Ltd Elsworth Clairmonte Marshall Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Male whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is:5 Date of last inspection 28th July 2006 Brief Description of the Service: Cascade House is a care home for five male service users with mental health needs. The home is situated in a residential street in Stamford Hill, within walking distance from an overground train station, shopping facilities and other local amenities. The home is located in a domestic property that blends in with other houses on the street. The premises are not wheelchair accessible. At the time of this inspection visit, there were 5 service users accommodated in the home. The company has recently been bought as a going concern and subsequently re-registered with the Commission for Social Care Inspection on 20/07/06 with the new name of Cascade Care Ltd. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit took place over one day and was unannounced. During this visit, the inspector spoke to four service users living in the home, the home’s manager and one member of staff working in the home. He also conducted a tour of the premises and viewed various records. Prior to this inspection the home was asked to complete the Annual Quality Assurance Assessment. Some of the information provided in the assessment has been incorporated into this inspection report. The aim of this unannounced inspection was to check the home’s compliance with the National Minimum Standards and the Care Homes Regulations. The inspector would like to thank service users and staff for contributing to this inspection. What the service does well: What has improved since the last inspection? There has been a change in the home’s management. Previous registered manager has moved to the new project opened by Cascade Care Ltd and the organisation recruited another home manager, who has recently been approved by the Commission as fit to manage residential care home for people with mental health issues. Since the last inspection, the home’s statement of purpose has been amended and the statement that the home provides services to “men who have past or present history of drug dependence or alcohol abuse” has been removed. The responsible person has ensured that all policies and procedures listed in Appendix 2 of the National Minimum Standards are up-to-date and kept under review. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 6 What they could do better: Following this inspection 14 statutory requirements were made, one of which has been repeated from the last inspection. These were: - The responsible person must ensure that all care staff receive all mandatory training, as required by law. - The registered manager must ensure that the home’s statement of purpose is updated to include information about the new registered manager. The registered manager must ensure that individual care plans are further developed, in order to demonstrate that all aspects of care included in the preadmission assessment have been taken into consideration. - The registered manager must ensure that each service user is offered keyworking session in accordance with their care plan and/or Care Programme Approach minutes. - The registered manager must ensure that all relevant risk assessments are drawn up and reviewed on regular basis, in order to ensure that any activities in which service users participate are so far as reasonably practicable free from avoidable risks and that unnecessary risks to health or safety of service users are identified and so far as possible eliminated. - The registered manager must ensure that he maintains records of food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. - The registered manager must ensure that appropriate systems are in place to monitor and record weight of any service users, where it has been deemed as necessary and/or beneficial to their wellbeing. - The registered manager must make appropriate arrangements for recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. - It is required that a record of any accident/incident is kept in the home in line with Regulation 17(2) of the Care Homes Regulations. - The registered manager must ensure that the broken lock is replaced on the service user’s bedroom, in order to allow privacy for the service user. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 7 - The registered manager must ensure that all service users’ bedrooms contain all fixtures and fittings listed in Standard 26, unless agreed otherwise in the person’s individual care plan, or being identified as their best interests. - The registered manager must ensure that all parts of the home are clean and hygienic. - The registered manager must ensure that staff personnel files contain all information listed in Schedule 2 of the Care Homes Regulations; in order to evidence that appropriate recruitment systems are in place. - The registered manager must ensure that staff receive supervision in line with the National Minimum Standards and appraisals on an annual basis. In addition, the following two good practice recommendations were made: - Any refusals from service users to attend keyworking sessions should be recorded. - It is recommended that records maintained in the home for recording finances kept on behalf of service users include space for staff to countersign any transactions made, in order to prevent any financial abuse. 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. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s statement of purpose required minor amendment. Good admission systems were in place. Prospective service users have an opportunity to “test drive” the home, prior to moving in. Each service user had a written contract in place. EVIDENCE: The inspector viewed the home’s statement of purpose and the service user’s guide. Since the last inspection, the home’s statement of purpose has been amended and the statement that the home provides services to “men who have past or present history of drug dependence or alcohol abuse” has been removed. The document required minor amendment to include information about the new registered manager. The registered manager must ensure that the home’s statement of purpose is updated to include information about the new registered manager. There has been one new admission to the home since the last inspection. Another service user has also been transferred from another residential home run by Cascade Care Ltd. The inspector viewed a care plan of the most recently admitted service user. His file contained a comprehensive assessment. There was also evidence that Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 10 appropriate and relevant information had been obtained from the placing authority. There was evidence in the service users’ files that they visited the home over a period of several weeks prior to admission, during which they had several overnight stays. Report from these visits were available for inspection. They were also forwarded to service users’ previous placements. All permanent service users had their contracts/statements of terms and conditions in place. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work was required to improve individual care plans. Service users were also encouraged to take part in planning their care and contributed to other aspects of life in the home. Further work was also required to ensure that appropriate risk management systems are in place. EVIDENCE: As part of this visit, the inspector viewed care plans of all five service users. Documents viewed by the inspector were quite basic and required further development to include issues such religion, culture, sexuality, assessment and management of risks etc. There was evidence that the service users were involved in the decision-making. Care plans were not always reviewed following important events in service users’ lives. The registered manager acknowledged that there was room for improvement to service user’s care plans. The registered manager must ensure that individual care plans are further developed, in order to demonstrate that all aspects of care included in the pre-admission assessment have been taken into consideration. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 12 The home operates a keyworking system. Each person had a designated keyworker, who was responsible for coordinating care of their keyclient. Keyworking sessions were also organised, during which any individual goals, progress and areas that needed further support were discussed. It was noted however that the frequency of keyworking sessions offered to each service user varied. The inspector was informed that some service users sometimes refused to take parts in keyworking sessions. The registered manager must ensure that each service user is offered keyworking session in accordance with their care plan and/or Care Programme Approach minutes. Any refusals from service users to attend keyworking sessions should be recorded. Regular service users’ meetings were also held, during which service users could make any comments and suggestions as to how the home should be run. Improvements were required to the home’s risk management systems, as at the time of this inspection not all necessary risk assessments were in place. The registered manager must ensure that all relevant risk assessments are drawn up and reviewed on regular basis, in order to ensure that any activities in which service users participate are so far as reasonably practicable free from avoidable risks and that unnecessary risks to health or safety of service users are identified and so far as possible eliminated. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users continue to take part in appropriate leisure activities. They are encouraged and supported to develop and maintain friendships and family links. Service users enjoyed food in the home, however improvements are required in maintaining records of food offered to each service user. EVIDENCE: Documentation viewed and conversations with the service users confirmed that those who use the service are encouraged to take part in the local community and to maintain and develop social, emotional and communication skills. Records viewed showed that service users visit their families and friends, attend cultural centres, do some of their own shopping and go out to cinemas, theatres and pubs. Some of these events are organised and facilitated by the home. One of the service users attended a motor mechanic’s course at the local college three times a week. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 14 Annual holidays are organised. This year some of the service users went on a holiday to Butlins. Families and visitors are welcome to the home. The home had a visitor’s policy in place. Visitor’s book was also maintained. Service users said that they were able to invite their friends and families into the home, subject to the home’s visitor’s policy and individual agreements as agreed by individual placing authorities. Meals offered by the home can be eaten in the dining room with other service users. There were appropriate food supplies in the home and service users spoken to said that they enjoyed food in the home. Fridge and freezer temperatures were recorded. Records of food offered to those living in the home was viewed. The inspector noted that it contained several entries such as “own choice” and “snacks”, which did not evidence whether nutritious and adequate food was offered. The registered manager must ensure that he maintains records of food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff did not always monitored weight of service users, where required. Medication systems required improvement. EVIDENCE: The inspector was informed that all service users who lived in the home at the time of this inspection attended their own personal care and staff only offered verbal prompts as and when required. There was evidence of an input from Psychiatrist, Community Psychiatric Nurses and Social Workers. The majority of the psychiatric reviews were carried out promptly. The majority of the service users choose to attend their GP surgeries and hospital appointments independently. In some cases staff accompanied service users to appointments. During this visit, the inspector spoke to the Community Nurse who was visiting one of the service users. He felt that the home was appropriately meeting the assessed needs of the person he was visiting. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 16 During the case tracking exercise, the inspector noted that staff did not always monitor weight of a service user, where concerns have been noted in relation to his food consumption and obesity. This required improvement. The registered manager must ensure that appropriate systems are in place to monitor and record weight of any service users, where it has been deemed as necessary and/or beneficial to their wellbeing. The home’s medication systems were also checked during this inspection visit. The following shortcomings were identified: - Staff did not always sign medication administration sheets to indicate whether medication has been administered to service users. - Records viewed were unclear whether medication was administered to a service user or whether it was given to him to take when on authorised leave. - Running balance of any PRN (as required) medication should be kept. - List of staff signatures should be kept for identify any person making entries of medication administration sheet. It is therefore required that the registered manager makes appropriate arrangements for recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate complaint systems were in place and those who used the service were aware of their right to complain. Improvements were required to ensure that those living in the home were protected from abuse. EVIDENCE: The inspector was informed that there have been no complaints made to the home since the last inspection. The home had a complaints policy in place, which included details of the Commission for Social Care Inspection. People who used the service were aware of their right to complaint. One service user told the inspector that he would feel confident to talk to the manager if he was not happy about anything in the home. Service users manage their finances, however support and guidance is offered to those service users who may require help in managing their finances, due to risk of substance abuse or money mismanagement. The inspector viewed records maintained in respect of finances kept on behalf of one service users. Whilst record of money was found to be correct, the inspector noted that only the service user was signing for money received from safekeeping. It is recommended that records maintained in the home for recording finances kept on behalf of service users include space for staff to countersign any transactions made, in order to prevent any financial abuse. There has been one adult protection issue in the home since the last inspection. Appropriate authorities have been informed and the matter was being dealt with. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 18 During the course of this inspection visit, one of the service users informed the inspector that he had to break the lock to his room as he mislaid his key and no spare keys were kept in the home. As a result, his room was kept unlocked and the service user’s privacy was compromised. The inspector was unable to establish how long ago this incident took place, as even though staff were aware of this incident, it had not been recorded. It is required that a record of any accident/incident is kept in the home in line with Regulation 17(2) of the Care Homes Regulations. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements are required to ensure that all parts of the home are decorated and maintained and that service user’s privacy is not compromised. EVIDENCE: The home is an ordinary domestic property situated in a residential street. The inspector carried out a tour of the premises, as part of this visit. As previously mentioned, it was brought to his attention by one of the service users that the lock on his bedroom door was broken. This meant that other service users could enter his bedroom uninvited. The service user felt that he could not have any privacy. In addition his room appeared to be untidy and required cleaning. His curtains were not properly hanging and his curtain rail was broken. The registered manager has stated that these issues have been reported to the Chief Executive and work was due to resolve outstanding issues was due to start imminently. In addition, there were plans to replace the current conservatory, as well as installing another shower in the house. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 20 The registered manager must ensure that the broken lock is replaced on the service user’s bedroom, in order to allow privacy for the service user. The registered manager must also ensure that all service users’ bedrooms contain all fixtures and fittings listed in Standard 26, unless agreed otherwise in the person’s individual care plan, or being identified as their best interests. Other service users who spoke with the inspector said that they were happy with their bedrooms. The premises were generally clean and hygienic, with the exception of the above mentioned bedroom. The registered manager must ensure that all parts of the home are clean and hygienic. Appropriate laundry facilities were in place. The home has recently purchased new washing machine. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Limited progress has been made in ensuring that staff have received mandatory training and any other training required for their job. Recruitment processes also required improvement. Staff were not always appropriately supervised. EVIDENCE: The inspector viewed duty rosters, which showed that there were sufficient numbers of staff on duty. There are two members on each shift, including nights. Night staff remain awake throughout the night. Staff who spoke with the inspector stated that staffing levels were sufficient to meet the needs of the current service user’s group. The majority of staff either have obtained the NVQ qualification or were in the process of obtaining one. Limited progress has been made in ensuring that staff have received mandatory training. As a result, the requirement in relation to staff training has been repeated and must be met without any further delay. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 22 Staff personnel files were checked. Some of them did not contain all information required by law. As applicants submit Curriculum Vitae and not application forms, gaps in employment were not always explored. This required improvement. The registered manager must ensure that staff personnel files contain all information listed in Schedule 2 of the Care Homes Regulations, in order to evidence that appropriate recruitment systems are in place. The registered manager stated that he was in the process of setting up supervision and appraisal systems in the home. The registered manager must ensure that staff receive supervision in line with the National Minimum Standards and yearly appraisals. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was managed by a competent manager, however he must ensure that all requirements resulting from this inspection visit are met. Appropriate quality assurance and health and safety checks were in place. EVIDENCE: As previously mentioned, the home has got a new registered manager in place who has recently been registered with the Commission as fit to manage a home for people with mental health issues. Throughout this visit, the inspector received positive comments about his performance and managerial skills from people who used the service and staff working in the home. The registered manager has a nursing qualification and appropriate managerial qualification. The new Responsible Individual has been carrying out “the Regulation 26 visits”, reports from which were being forwarded to the Commission. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 24 Since the last inspection, the organisation has reviewed its policies and procedures, as previously required. Appropriate health and safety checks were in place. The home was adequately insured for its purpose. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 x 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 3 X Cascade Care Ltd (Cascade 1) DS0000067294.V352955.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 YA35 Regulation 19(5)(b), 23(4)(d) Requirement The responsible person must ensure that all care staff receive all mandatory training, as required by law. (Previous timescale of 01/12/06 was not met.) The registered manager must ensure that the home’s statement of purpose is updated to include information about the new registered manager. The registered manager must ensure that individual care plans are further developed, in order to demonstrate that all aspects of care included in the preadmission assessment have been taken into consideration. The registered manager must ensure that each service user is offered keyworking session in accordance with their care plan and/or Care Programme Approach minutes. The registered manager must ensure that all relevant risk assessments are drawn up and reviewed on regular basis, in order to ensure that any activities in which service users DS0000067294.V352955.R01.S.doc Timescale for action 01/02/08 2. YA1 4(1)(c), 6(a) 01/12/07 3. YA6 15(1) 15/12/07 4. YA6 12(2), 12(3) 15/12/07 5. YA9 13(4)(b), 13(4)(c) 15/12/07 Cascade Care Ltd (Cascade 1) Version 5.2 Page 27 6. YA17 17(2) Schedule 4.13 7. YA19 12(1)(a) 8. YA20 13(2) 9. YA23 17(2) Schedule 4.12 12(4)(a) 10. YA24 YA26 11. YA26 16(1)(c) participate are so far as reasonably practicable free from avoidable risks and that unnecessary risks to health or safety of service users are identified and so far as possible eliminated. The registered manager must ensure that he maintains records of food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. The registered manager must ensure that appropriate systems are in place to monitor and record weight of any service users, where it has been deemed as necessary and/or beneficial to their wellbeing. The registered manager must make appropriate arrangements for recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. It is required that a record of any accident/incident is kept in the home in line with Regulation 17(2) of the Care Homes Regulations. The registered manager must ensure that the broken lock is replaced on the service user’s bedroom, in order to allow privacy for the service user. The registered manager must ensure that all service users’ bedrooms contain all fixtures and fittings listed in Standard 26, unless agreed otherwise in the person’s individual care plan, or being identified as their best interests. DS0000067294.V352955.R01.S.doc 01/12/07 01/12/07 01/12/07 01/12/07 15/11/07 01/12/07 Cascade Care Ltd (Cascade 1) Version 5.2 Page 28 12. 13. YA30 YA34 23(2)(d) 7, 9, 19 Schedule 2 14. YA36 18(2) The registered manager must 01/12/07 ensure that all parts of the home are clean and hygienic. The registered manager must 01/12/07 ensure that staff personnel files contain all information listed in Schedule 2 of the Care Homes Regulations; in order to evidence that appropriate recruitment systems are in place. The registered manager must 01/01/08 ensure that staff receive supervision in line with the National Minimum Standards and appraisals on an annual basis. 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. 2. Refer to Standard YA6 YA23 Good Practice Recommendations Any refusals from service users to attend keyworking sessions should be recorded. It is recommended that records maintained in the home for recording finances kept on behalf of service users include space for staff to countersign any transactions made, in order to prevent any financial abuse. Cascade Care Ltd (Cascade 1) DS0000067294.V352955.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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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