Inspection on 14/03/06 for Cavendish Residential Care Home Limited

This inspection was carried out on 14th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cavendish Residential Care Home... 28/06/07

Cavendish Residential Care Home... 03/07/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Cavendish Residential Care Home Limited Cavendish Residential Care Home 26 Kings Road Clacton on Sea Essex CO15 1AZ Lead Inspector Tim Thornton-Jones Announced Inspection 14th March 2006 10:30 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 Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cavendish Residential Care Home Limited Address Cavendish Residential Care Home 26 Kings Road Clacton on Sea Essex CO15 1AZ 01255 423861 01255 423114 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) Cavendish Residential Care Homes Limited Manager post vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 21 persons) 4th October 2005 Date of last inspection Brief Description of the Service: Cavendish is a care home, providing personal care and accommodation for 21 older people. The service is managed by Mr and Mrs Hunt, who have owned the home since 2000, however, have recently registered as a Limited Company. The home is located on the outskirts of Clacton town centre and has easy access to the local shops and other amenities. The home consists of a two storey, detached house. The bedrooms are made up of nineteen single and one double room. All but three of the rooms have ensuite facilities. There is a passenger lift. The home has private gardens, which are well maintained and accessible via a ramp. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is principally based upon an inspection undertaken on 14th March 2006, although makes reference to an inspection undertaken on 4th October 2005. Following the 4th October inspection, a letter was sent to the Registered Persons that included actions and recommendations arising. No published report was made. The 4th October 2005 inspection concluded that the Registered Manager, Mrs C Hunt, delegated increased responsibility for the daily operation of the home to her Deputy Manager, Mrs D Wright, who was referred to, by staff at the time, as the Manager. The inspection highlighted several shortfalls in the delivery of the service. This latter inspection will make some reference to these shortfalls within the appropriate sections of this report, however, the overall position has improved within the period since Oct 2005. There remains further improvements to be achieved to ensure satisfactory compliance with National Minimum Standards and the overall outcome for service users. At the time of writing this report Mrs Wright had applied to become the Registered Manager of Cavendish Care Home. This application remains under consideration, following a fit person interview. In view of the proportion of National Standards that were inspected as not meeting the minimum requirement, and that the home does not have a registered manager, CSCI will continue to monitor the service at suitable frequency to ensure that improvements are implemented. What the service does well: • • A homely and domicile environment is maintained. Overall, the home is maintained in a safe and hygienic way. (Notwithstanding recommendations made within this report.) What has improved since the last inspection? • • Arrangements for the safe custody of service users’ finances. Support of service users by staff. DS0000062449.V291671.R01.S.doc Version 5.1 Page 6 Cavendish Residential Care Home Limited What they could do better: 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. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 • • • • Service users did not benefit from adequate information on which to make suitable choice about the service. Examples of the statement of terms and conditions showed that the required arrangements were not maintained. Service users, admitted, did not all receive ongoing assessment of their needs. The service was not able to demonstrate that service users’ known needs could be reliably met at all times. EVIDENCE: The Statement of Purpose, requested at the time of inspection, did not meet the requirements of National Minimum Standards or regulatory requirements. Subsequent to the inspection the person in control was advised of this and a revised version of the document was forwarded to CSCI. On inspection of this document it was found to contain the information required. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 9 Not all service users were issued with a ‘guide’ document, as required by National Minimum Standards and regulation, which contained all of the required information. The document seen indicated that a number of elements were not included. Attached to the Statement of Purpose was the home’s terms and conditions. This did not include the fees payable, and by whom, the rooms to be occupied and the terms and conditions of occupancy, including the period of notice. This document is therefore in need of revision along with the Service Users Guide. From a sample taken at both the Oct 2005 and March 2006 inspections, records examined indicated that service users had been assessed as to their needs prior to living at the home. National Minimum Standards require that each service user has a plan of care based upon the pre-admission assessment or the home’s own assessment approach. The care plans were unable to evidence this on both inspection occasions. The staff employed at the home, observed at the Oct 2005 inspection, were not all able to demonstrate, individually or collectively, the range of skills required to evidence the home’s capacity to meet the needs of service users admitted. Further comment regarding this is made elsewhere within this report. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 & 11 • • • • Arrangements for care management do not fully support service users’ needs. Service users’ healthcare needs are not fully met. Service users were not treated with respect at all times by all staff. Service users are not reassured that their wishes and beliefs will be respected at the time of their death. EVIDENCE: The methodology used at both inspections was a ‘case tracking’ approach, whereby, as far as practicable, the service to a sample group of service users is examined from a variety of viewpoints and perspectives in order to ‘link together’ the overall service to the person. The overall structure of the care plan was adequate, although the content of information gathering was variable in quality. There was little evidence found of consultation with service users about their wishes and choices. Some of the Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 11 information contained was positive and there were some sound examples of physical and personal care needs, however, little around social, emotional and leisure needs. Overall, the care planning arrangements were reflective of a ‘medical model’ approach. The daily recording was somewhat predictable and unhelpful for the most part, containing frequent phrases such as ‘all care given’, ‘meds taken’, and ‘good diet’. Entries in care notes were repetitive and appeared to show that staff were merely repeating the previous entry. Further example of an apparent lack of consultation and choice was linked to the use of plastic beakers, used for drinks at mealtimes, which all service users were given. When the use of these cups were raised during the Oct 2005 inspection, the Deputy/Acting Manager advised that service users ‘liked them’ because they worry about dropping and breaking glass ones. None of the care plans showed any consultation about this, nor were any risk assessments in place regarding the issue of glasses as a presenting risk. The Inspector advised that credible and safe alternatives were available, rather than plastic beakers, such as toughened glasses, which are difficult to break. Any departure from equipment that would be of normal use should be subject to assessment of risk. The use of plastic beakers in any other circumstances does not promote dignity or provide suitable choice. The Deputy Manager advised that some service users enjoy a glass of sherry, this being served in a standard sherry glass, which rather confused the issue regarding safety. The situation had not altered by the time of the second inspection during March 2006. On one sample care plan it was noted that the pre-admission assessment indicated an individual to have ‘special needs’. A subsequent assessment showed the person had none, although no explanation for the variance was apparent. Several of the samples were unsigned by the service user and there was no clear evidence to show that the individual was integral to the plan or had contributed to it. This was the case at both inspections. None of the care plans sampled indicated that the sensitive, but important, matter of cultural and faith beliefs had been addressed, particularly regarding end of life issues. A key worker system was stated to be in operation, although there were no obvious indications within the care plan documentation as to how this approach is managed or links to meeting service users’ needs. Primary healthcare arrangements were satisfactory, such as optician and Chiropody etc. At the time of the second inspection a GP visited to see a service user. This was managed in a dignified and appropriate manner. None of the care plan samples indicated that service users benefited from nutritional screening at admission or subsequently. There were examples of Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 12 specific risk assessment details and some care plans included individual recording sheets, for example fluid intake. The frequency of care plan review was variable. One care plan seen had not been reviewed since January 2005. There were concerns regarding the practice of some care workers during the Oct 2005 inspection. As part of a case tracking approach the Inspector, for part of the inspection, sat in the lounge area chatting to service users and observing practice. One service user was heard to ask a student to be assisted to the toilet. The young student correctly advised the service user they were not permitted to assist in this way and told the service user they would find a carer. The Inspector timed the request to ascertain how long it would take for the service user to be assisted, as requested. After 17 minutes had elapsed, the Inspector asked the student, who had re-entered the room, who they had asked to assist the person. The carer who over heard this stated it was they who had been asked by the student, but had not assisted the person because they had stated the service user ‘changed their mind’ and wanted to go to the toilet after lunch. The carer then, before the Inspector could challenge this, went to the service user to ‘remind’ the person that her account of events was correct. Fortunately the service user, to their credit, asserted that they ‘had said no such thing’ and had been waiting ‘a long time’. The carer then left the lounge. Another carer then took the service user to the toilet and proceeded to reassure the service user who by now, in the opinion of the Inspector, was showing signs of distress. Fortunately, the Inspector had made a point of remaining in the lounge close by to the service user for the purpose of assessing response time throughout this relevant period. The carer had not, in fact, spoken to the service user during the period in question and the service user had been ignored. This was an example of very poor practice and one that was reported to the registered person who was advised to improve the culture within the home. At the second inspection in March 2006 some examples of good practice was observed. Unfortunately a further example of institutional and rather oppressive practice was observed during the Oct 2005 inspection. When the Inspector entered the lounge, two carers and a student were speaking with service users asking various questions. It became quickly apparent that carers were completing a quality questionnaire by asking service users their views. With the exception of the student, who was attempting to explain the questions to the service user to illicit a reliable response, the remaining carers were conducting themselves, in the opinion of the Inspector, in an oppressive fashion. Both carers asked very leading questions and, for the most part, persuaded service users to respond positively. Where no response was obtained, the carer ‘decided’ what the service user would probably like. One carer had a strong accent and the service user was observed to not understand the question, or the way it was being asked. This was put to the service user several times until the carer gave up and put the answer they thought was best. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 13 The Registered Person entered the room at one point, when one carer was being quite loud and persuasive with one service user who was hard of hearing. The Inspector, having witnessed the way this ‘quality’ questionnaire was being conducted for several minutes, asked the Registered Person to stop the process to avoid any further harassment of some service users. The Registered Person responded immediately, recognising the inappropriateness of the circumstances and advised later that this had been the first occasion that carers had been asked to assist with quality questionnaires. It was agreed that the questionnaires would be discarded and staff would receive training before this approach was repeated. See comments linked to National Minimum Standard 33. It is nevertheless unfortunate that care staff were not appropriately assessed as competent to undertake this task before delegating it to them. See National Minimum Standard 30. Care plans sampled during the March 2006 inspection showed little improvement since the previous October 2005 inspection. One service user, admitted at the beginning of February 2006, had virtually no information recorded or decisions made in relation to their care. Comments such as ‘confused, requires supervision’ are very unhelpful and inappropriate. The pre-admission information identified the person as having a serious lung condition, but the care plan made no reference to the support the person required in relation to this. Current prescribed medicines were listed, although no information was on the plan regarding side effects of these drugs. The pre-admission information highlighted that the person required considerable care in relation to continence management, although the plan had no decisions or care methodology evident in relation to this. Pre-admission information also advised that the person had an appointment on 6th Feb 2006 to attend an x-ray appointment. The care plan made no reference to the post appointment follow up arrangements. The practice described within this section, which covers both inspections indicates that National Minimum Standards are not being achieved and the Registered Persons will need to undertake a professional audit, or similar approach, to identify why practice and procedures are failing. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 & 15 • • • Service users benefit partly from a social programme. Service users do not fully benefit from choice and control over their lives. Service users receive a balanced diet. EVIDENCE: Records seen indicated that the home has themed days or celebration events, such as St Patrick’s Day and St George’s Day. Indoor activities include bingo and other group games and there are some visiting entertainers. It was noted that a meeting of service users was held during the week prior to the March inspection. It was noted on both inspections that the lounge area has two TVs. On the day of the March inspection both were turned on and tuned to different channels. The inspector noted that both TVs could be heard from anywhere in the room. The Registered Person is urged to discuss this with service users to improve the situation. The care plans sampled placed relatively little emphasis upon obtaining relevant information regarding social and emotional aspects of service users’ Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 15 lives. Decision making about these aspects is disproportionate in relation to physical needs and would benefit from a higher priority within planning. Whilst the information available to service users was positive regarding social events, and the existence of meetings periodically is encouraging, the planning structure around care management does not engage with a culture of personcentred practice. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 • Service users are not fully protected from the home’s complaint procedure and adult protection system. EVIDENCE: The CSCI are aware of one complaint about the service, which was upheld following intervention by CSCI. The conclusion reached was that the home had not responded appropriately to the original complaint to the home. The service did not follow its own procedure in this circumstance. Some of the information gathered as a result of the two inspections gives an indication that the culture of the service is in need of improvement to ensure that service users are protected from potentially harmful practice and protected from abusive attitudes and practice. It is important to also emphasise that, during the same period, good examples of practice were found and some staff demonstrated a clear positive commitment to service users. The concern is somewhat amplified by the apparent co-existence of these variable practices with outcomes for service users that can strongly point to quality concerns of the day to day management of this service. The adult protection procedure was satisfactory, although remains in need of development to ensure that it clearly links with the referral process of the lead agency in protection matters. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 & 26 • • • Service users do not fully benefit from a well maintained environment. Service users do not have access to a suitable number of baths. Service users do not fully benefit from a home that is always hygienic. EVIDENCE: Overall, the home presents as domicile in character, although the fluorescent strip lighting in the lounge is not acceptable in care homes and should be replaced in favour of a more aesthetic alternative. Furniture and fittings were, overall, satisfactory. There are some improvements to be made to the décor in various parts of the home. The Inspector was advised (Oct 2005) that one bath (of three in the home) was not working due to a leak. The water to this bath had not been turned off and remained inoperable at the March 2006 inspection. This is unacceptable. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 18 A plan and timescale for bringing this bathroom into operation must be drawn up and forwarded to CSCI without further delay. The Registered Persons have not evidenced that a suitably qualified person, in relation to the service user group, has assessed the premises and this should be undertaken. It was noted that some communal facilities had bar soap provided. These were noted to have dried and cracked and present as a potential cross infection risk. During the Oct 2005 inspection one room in particular was found to have an unpleasant odour. No odours were detected during the March 2006 inspection. The premises, overall, were tidy and clean. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 • Service users do not fully benefit from a well trained, supervised and appropriately recruited workforce. EVIDENCE: Six staffing records were sampled in relation to the information held regarding recruitment practice, training and development, and the way the organisation supports and supervises their carers. A cross section of Senior Carers, Carers and Support Workers were sampled. Of these, none of the files sampled showed that all of the statutory information required was being maintained. Four of the six sampled did not have a Criminal Record Bureau (CRB) certificate. Various other omissions were found. The Registered Person must undertake an audit of all staff files to ensure that all of the required information is obtained and kept. The arrangements regarding training and development are in need of review and improvement. Whilst a training record is maintained for care staff, it was unclear as to the service strategy to ensure that staff possess the appropriate knowledge and skills, relevant to the work they are expected to do. There was no assessment of the service requirements or of the existing knowledge and skills within the staff group. Based upon a sample of four care workers, in relation to the range of skills and competencies the workers require in terms of the intended service outcomes, Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 20 gaps were found in training needs. None of the sampled files contained evidence of workers having undertaken essential training such as Protecting Vulnerable Adults (POVA), Care of Frail Older People, Food Hygiene, First Aid, and Supervisory Skills (where appropriate). The records did show that the entire sample had attended a Moving and Handling course, two had attended a Medicines course, one had attended Continence Management training and all had attended Fire Training. In addition, two of the four carers were currently working toward an NVQ qualification, which was positive. The Registered Person will need to review arrangements for recruitment and induction, and training requirements in order to meet requirements of National Minimum Standards. The observed outcome of some poor staff practices during the Oct 2005 visit may have been symptomatic of inadequate supervision and staff training. The care outcomes were observed to have been improved at the time of the March 2006 inspection and this was positive. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 37 • • • • Service users do not fully benefit from a well managed home or are not assured of a positive ethos and leadership. Service users do not benefit from the service quality and monitoring systems. Service users’ wellbeing would be improved by further development of staff training, development and supervision. Service users are not fully protected by the home’s record keeping and practice procedures. EVIDENCE: At the time of the October 2005 inspection a carer, who stated they would make an introduction to the Manager, greeted the Inspector. The Inspector Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 22 was introduced to Ms D Wright, who is stated in the home’s information as the Deputy Manager. Ms Wright also referred to her role as the Manager and was, throughout the inspection, directing the day-to-day care. Subsequent discussion with the Registered Managers, Mr and Mrs Hunt, they confirmed that Ms Wright was their deputy manager but was supporting Mrs Wright in taking a lead in view of the intention to make application for her to become registered as manager. At the time of writing this report an application for Mrs Wright was being progressed. Based upon the outcomes of both recent inspections a significant number of National Minimum Standards are not being fully met, although the March 06 inspection noted an improvement. The Registered Persons will need to review the management arrangements and to ascertain the reason why an increase in non-compliance has been found since previous inspection outcomes. On this basis the two inspections to which this report refers concludes that National Minimum Standard 31 is not currently being met. The ethos and management of the home was in considerable doubt following the October 05 inspection as reported previously within this report, and whilst a general improvement was noted in the subsequent inspection in March 06, the degree of non-compliance with National Minimum Standards that remain supports a view that further improvement and development are required to ensure that the culture within the home is reflective of safer practice. The approach to quality assurance and quality monitoring observed during the October 05 inspection was very poor. These observations support the view that staff were asked to undertake a task that they were evidently not adequately skilled to do. The quality assurance and quality monitoring approach is not sufficiently developed to ensure that the service delivery has the capacity to operate at the level required to meet National Minimum Standards and therefore the approach requires review. The financial procedures and accounting matters were not fully inspected. The arrangements regarding the manner in which the home manages cash held in safe custody was sampled. During the October 05 inspection several errors were noted to both balances and procedures. By the time of the March 06 inspection these had been corrected. The Registered Person will need to review the procedures to ensure that the accounting arrangements remain suitably controlled and accounted for at all times. The home was unable to provide evidence that staff are appropriately supervised in accordance with the practice and frequency set out within National Minimum Standards. This requires improvement and development. A small sample of statutory records was examined at random. Those found not to comply with regulatory requirements were; Service users guide, record of persons employed, supervision and associated records. The Registered Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 23 Person will need to undertake an audit of all statutory record keeping ensuring that all are maintained in accordance with regulation. The Registered Persons have recently completed a registration process to form a Limited Company. On this basis the Company must ensure that one or more of the directors completes a visit and reporting procedure under Regulation 26 of the care Homes Regulations 2001. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 24 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 2 2 2 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 1 X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 1 2 X Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 25 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 Timescale for action The Registered Person must 30/05/06 ensure that the Service Users Guide is issued to all service users and that it meets with regulatory requirements. This is a repeat requirement. The Registered Person must 30/05/06 ensure that each service user has written terms and conditions. This is a repeat requirement. The Registered Person must 30/05/06 ensure that each person has a care plan reflective of all the assessed needs of service users. This is a repeat requirement. The Registered Person must 30/05/06 ensure that the home is able to demonstrate the capacity to meet the needs of service users admitted. This is a repeat requirement. The Registered Person must 30/05/06 ensure that the service user plans provide the basis for the care to be delivered. This is a repeat requirement. The Registered Person must 30/05/06 ensure that service users’ DS0000062449.V291671.R01.S.doc Version 5.1 Page 26 Requirement 2 OP2 5 3 OP3 15 4 OP4 4,5,9,12, 13,15,16 18,19,24 5 OP7 15 6 OP8 12, 13 Cavendish Residential Care Home Limited 7 OP10 8 OP14 9 10 OP16 OP18 11 12 OP19 OP21 13 OP27 14 OP28 15 OP29 16 OP30 healthcare needs are monitored. This includes nutritional screening. This is a repeat requirement. 12,13,15, The Registered Person must 18,19,24 ensure that service users receive dignified care at all times. This is a repeat requirement. 5, 12, 14 The Registered Person must ensure that the home is conducted in a manner so as to maximise service users’ capacity to exercise personal autonomy and choice. 22 The Registered Person must ensure that the procedure for managing complaints is followed. 13, 18, 24 The Registered Person must ensure that practice within the home meets the requirements of the protection of vulnerable adults policies and procedures. This is a repeat requirement. 23 The Registered Person must ensure that the home is well maintained. 23 The Registered Person must ensure that service users have access and use of suitable and adequate bathing facilities. 18 The Registered Person must ensure that the skill mix of carers is adequate to meet the needs of service users. This is a repeat requirement. 18 The Registered Person must ensure that staff are trained to the requirements of National Minimum Standards. 19 The Registered Person must ensure that staff are recruited in accordance with regulatory requirements. 18 The Registered Person must ensure that there is an adequate training and development programme for staff. This is a repeat requirement. DS0000062449.V291671.R01.S.doc 30/05/06 30/05/06 30/05/06 30/05/06 30/05/06 30/05/06 30/05/06 30/05/06 30/05/06 30/05/06 Cavendish Residential Care Home Limited Version 5.1 Page 27 17 OP31 9 18 OP32 4,5,12, 13,22,24 19 OP33 12, 24 20 OP36 18 21 OP37 17 The Registered Person must ensure that daily ongoing management duties are undertaken by a person registered as fit by CSCI. This is a repeat requirement. The Registered Person must ensure that service users benefit from the leadership and management approach of the home. This is a repeat requirement. The Registered Person must ensure that the home is run in the best interest of service users. This is a repeat requirement. The Registered Person must ensure that care staff are appropriately supervised. This is a repeat requirement. The Registered Person must ensure that records required by regulation are adequately maintained and available for inspection. 30/05/06 30/05/06 30/05/06 30/05/06 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP26 OP11 Good Practice Recommendations The Registered Person is recommended to ensure that the home refrains from using communal bar soap to reduce the risks of cross contamination. The Registered Person is recommended to further develop strategies and arrangements, as part of service reviews, for issues associated with end of life. The Registered Person is recommended to review the light fittings in the lounge area. The office style strip lighting is not in keeping with a domestic environment. DS0000062449.V291671.R01.S.doc Version 5.1 Page 28 OP20 Cavendish Residential Care Home Limited 4 OP22 The Registered Person is recommended to review the use of two televisions within the lounge area. A number of service users were hard of hearing and the use of both TVs is likely to cause an unreasonable annoyance. Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cavendish Residential Care Home Limited DS0000062449.V291671.R01.S.doc Version 5.1 Page 30 - 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!