Inspection on 03/07/06 for Cavendish Residential Care Home Limited

This inspection was carried out on 3rd July 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... 14/03/06

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, Diane Roberts Unannounced Inspection 3rd July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cavendish Residential Care Home Limited DS0000062449.V302963.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. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 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.V302963.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Pesons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 21 persons) 14th March 2006 Date of last inspection Brief Description of the Service: Cavendish is a care home, providing personal care and accommodation for 21 older people. Mr and Mrs Hunt, who have owned the home since 2000 and have recently registered as a Limited Company, manage the service. 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. The current scale of charges is £358.00 - £430.00. Additional costs for items such as hairdressing, chiropody are charged separately. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a full day and was carried out as part of the annual inspection programme for this home. The Proprietor was present at the inspection. The Inspection focused upon all of the key standards and the homes response to the last agenda for action. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. Residents and staff were spoken to on the day of the inspection. As part of the Commission approach to seeking a wider review of opinion about the service provided by Cavendish Care Homes Ltd, Mrs Hunt, the responsible individual, was asked prior to the inspection to submit the names and addresses of relatives of persons residing at the care home in order for the Commission to send them a questionnaire. The information had not been received at the time of the inspection visit. Mrs Hunt was asked why the information had not been forwarded to the Commission. Mrs Hunt stated that she had consulted with relatives and they had all told her they were not prepared to give their identities to the Commission and would rather the questionnaires be sent to them via the home. This will be considered at the next inspection. At the time of writing this report the home is undergoing an Adult Protection Investigation. What the service does well: What has improved since the last inspection? What they could do better: Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 6 The home has a significant amount of work to do in order to meet with National Minimum Standards and Care Standard Regulations. Shortfalls were noted in relation to Care planning and care records, the healthcare and care of residents and the safe administration of medication. Staff also need to evidence a better appreciation of residents dignity and the right to have choice and control over their lives. Systems for dealing with complaints and the protection of vulnerable adults need to improve along with staff training and recruitment in general. 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.V302963.R01.S.doc Version 5.2 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.V302963.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The pre- admission assessment of residents coming into the home shows significant shortfalls. EVIDENCE: The home has a pre printed pre admission assessment tool in place, which covers all the required areas. Inspection of these documents found that completion of these was poor, giving very limited information as to why residents were being admitted and the care needs of the individual. This does not evidence that the home has assessed that they can meet the needs of the prospective resident and acted in their best interests. At the current time the deputy manager reports that she has been undertaking the pre admission assessments. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have individual plans of care in place but shortfalls are evident that need to be addressed and the new system needs to develop. Residents do not always receive the health and personal care they require. The safe handling and administration systems for medication are poor. The dignity and privacy of residents is generally maintained. EVIDENCE: The home has recently introduced a new care planning system and this was inspected along with records from the old system. The new pre-printed system covers all the required areas and includes risk assessments. At this time of change over, some of the residents do not have a full care plan in place, available for staff to use, although the majority of the assessment work has been carried out. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 10 The new pre printed system consists of a comprehensive assessment, which ultimately provides a score linked to a separate care planning section. On inspection not all sections of the new care planning system had been completed. Some of the care plans seen, did contain sufficient detailed information whilst others did not. For example, ‘apply cream’ but it is unclear as to what should be applied and ‘use pads’ but no information as to what pad should be used. Particular shortfalls were noted with respect to mental health wellbeing assessments and care plans and social preferences/choices and subsequent care plans. Staff may required more guidance in this area in order to understand and appreciate residents needs. In parts of the assessment, staff identified a mental health need and then no subsequent care plan had been put in place. Work needs to be done to ensure that all the required care plans are in place. From observation of the residents, the care plans that were in place were not all up to date and as yet staff are not using the additional add on documentation to provide further care plans that are not pre-printed. One resident was noted not to have care plans in place for pain relief, mouth-care and sore groins. At the current time none of the care plans inspected evidenced either resident or relative input. Daily notes are being completed. Some were seen to be informative and related to the care provided and how the resident had spent their day whilst others were repetitive or inappropriate stating that ‘ x messed herself’ and ‘unsettled night has been buzzing for silly things all night’. This needs to be discussed with staff regarding their approach to residents. The staff have recently completed a significant amount of work on the assessment of residents including a range of risk assessments. These include manual handling, nutritional, personal risk etc. Risk assessments for pressure sores have been completed and some residents have been identified as high risk. However, no records are available to show what action the home has taken to reduce or address this risk. This needs to be addressed to ensure that the residents are being appropriately referred and assessed for equipment, should they need it. Some of the manual handling assessments are misleading and could be confusing for staff and limit residents’ independence. For example, one assessment says a resident is totally immobile/high risk, but they do actually walk with a frame. A management overview may be of value to ensure all the information is correct. Records show appropriate GP involvement in the care of residents and the District Nursing team are visiting the home to see residents as required. Records evidence that residents see the chiropodist, optician etc. Residents spoken to were happy with these services at the home. Full weight monitoring records were not available due to the change over in systems but records point to regular weighing of residents. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 11 Attention to detail is needed with some of the care provided to more dependant residents and one resident was noted to have a very dry mouth and coated tongue despite having fluids next to her. When examining old care documentation for one resident, documents and blood test forms were found for a current resident, with an accompanying letter asking that these blood tests be carried out in March 2006. This was discussed with the deputy manager, who was unable to explain why this had not been done. The home needs to ensure that resident’s healthcare needs are met and that systems are in place to ensure there are no oversights. Systems for the safe handling and administration of medication at the home are poor. The home uses a blister pack and bottle to mouth system. Records show that staff check medications in when received, but this system was seen to be inconsistent, with medications either not being carried over from sheet to sheet or not being checked in at all. Signing for medications was generally sound on the day of the inspection, with only odd omissions. Staff need to use the omission code system to better effect and evidence that p.r.n medications have been offered. However, one MAR sheet evidenced very poor recording for one resident where it was unclear whether the resident did or did not receive her medication at all. This was compounded by the inconsistent approach of staff as the whether the resident was or was not self-medicating. The resident had signed a selfmedication sheet upon admission to the home but it is in question as to whether this resident was able to manage this and whether the home was acting in her best interests. The care of this resident in relation to her administration of medication was very poor. Hand written prescriptions were noted on the MAR sheets and these did not all have dates and signatures. This needs to be addressed. No dates of opening were recorded on the liquid or boxed medications providing only a limited audit trail. Old medications for deceased residents were found in the medication cupboard, which should have been returned to the pharmacy some time ago. On examination of the blister packs, it was noted that tablets had been used from the end of the pack if a tablet had been dropped/spoilt etc. The deputy manager reported that the unused tablets, of which there was no evidence, were disposed of down the toilet. This is an unacceptable practice and was discussed with the proprietor. Loose tablets, unboxed, were noted in baskets in the medications cupboard, with staff informing the inspector that these were used for homely remedies. Some of these tablets were not seen as suitable for a homely remedy and the staff could not supply an agreed homely remedy list/policy. The home has a returns system in place and records evidence recent returns. There is obviously an inconsistent approach to this system. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 12 Resulting from discussion with service users, observation of practice and of the records held within the care home it was evident that on the day of inspection, staff were observed to be courteous and supportive toward service users. Some service users spoken with expressed a view that most staff they encountered were helpful and cheerful, although not all. Service users spoken with said that overall they did receive care in a manner that they felt was appropriate, although on odd occasions did feel rushed. Residents said that staff answered the buzzer promptly and were good with maintaining their dignity and respecting their privacy. It remains a concern as to how staff refer to residents in the daily notes, see Standard 7, in relation to a dignified and respectful approach by care staff. The management of the home should consider staff training. Service users have access to a telephone, although there is no separate incoming line for this. The handset is of the portable kind and this is taken to the service user for an incoming call so that privacy can be achieved. Service users who do not have their own telephone would need to request the home telephone from staff. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do not benefit from an individual approach to social, emotional, gender and cultural assessment of their needs and preferences. Service users friends and relatives are made welcome. Service users do not benefit fully from being offered choice and control over their lives. The home provides a satisfactory meals service. EVIDENCE: The outcomes for the standards assessed within this group were concluded as a result of discussion with service users, observation of practice, records and policy/procedure documents. Available on notice boards located in service user areas were information relating to themed events and days within the home. On display were photographs of a recent Barbeque. Service users spoken with confirmed that a music session was being held weekly, provided by a visiting musician, although Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 14 overall there was mixed enthusiasm for this and other events. It was accepted that on the day of inspection service users were feeling the effects of a very hot day and this may be reflected in the responses given. It is important to ensure that in addition to advertising various events within the home, a robust approach be developed to ensure that each person is consulted about individual likes and preferences and that the outcome is represented within the care planning and review of service users. Some social records were available for inspection, which evidenced events at the home. Arrangements for service users to maintain contact with relatives and friends are set out within the homes policy documents. No relatives were spoken with at the time of this inspection, however, based upon discussion with service users, relatives and visitors are welcomed by the home. Records of a service user admitted, and subsequently admitted to hospital, were reviewed. The circumstances of the admission indicated that the service user or their relative were not informed adequately of how to contact external agents who will act in their interests, for example, financial support. The nature and arrangements of the admission for this person was not reflective of satisfactory choice, personal autonomy and consultation. This matter is at the time of completing this report being considered under complaint procedures, the outcome of which will be summarised within the next CSCI published report. Residents who expressed a view also stated that they were able to exercise choice in relation to when they went to bed and how they spent their time during the day. Personal preferences and choices are listed in some but not all the care plans and this needs work to ensure that staff are aware of these. Lunch seen to be a calm affair with residents being helped sensitively and wearing clothes protectors where appropriate. Lunch looked appetising. The home has a set menu, which looks appropriate for the resident group, varied and nutritionally sound. A set menu is available every lunchtime for residents to see, with alternatives available if the resident requires it. Alternatives are provided on an individual basis. Good records are kept of the actual daily menu served and on what residents actually ate. Service users spoken with, and who expressed a view, stated that the meals provided were acceptable overall, although one service user spoken with who is vegetarian, stated that in her opinion the home does not adequately cater for vegetarians and that she regularly buys her own food. This was discussed with Mrs Hunt, the responsible person, who stated that she and the Cook at the home were vegetarian and providing a vegetarian meal for the service user was not a problem but that the person preferred to purchase part of her own diet herself. It is recommended that a suitable menu be agreed with the service user and that should the service user remain of the view they wish to purchase part of their own dietary requirements, a suitable arrangement is in Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 15 place to ensure fair and equitable funding is agreed between the home and service user. Cavendish Residential Care Home Limited DS0000062449.V302963.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The arrangements for the receipt and investigation of complaints and safeguarding arrangements do not meet adequate standards of practice. The home has systems in place, which help to ensure that residents are protected from abuse but these have significant shortfalls. EVIDENCE: The inspection highlighted that the home had a recorded incident of an assault having occurred between two service users and that this incident was being responded to as a complaint by the home. The nature of this matter was such that is was reportable to the Commission. The Commission was unaware of the matter. The home has a policy and procedure regarding complaints and this meets with requirements. The Commission became aware of a complaint that had been made to the home by a relative prior to the inspection. Both Mrs Hunt and the Deputy Manager were asked at the time of inspection if the home had received any complaints other that the one already referred to, which they confirmed they had not. There is a discrepancy in the response received since it has been clearly established that a complaint had been formally made to the home and that the Deputy Manager had verbally responded to. The homes complaint procedure in this instance was not followed. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 17 The complaint was also potentially a criminal matter and as such should also have been reported by the home to the local authority and to the Commission as a safeguarding adults referral. This was not done. The homes policy and procedure regarding safeguarding adults does not meet requirements on the basis that it did not clearly establish a referral link with the lead body for Protection of Vulnerable Adults. This matter is currently under review by the Commission and will be reported upon within the next published report of this service. The Registered Person will need to ensure that a review is undertaken of all policies and practice procedures to ensure that each reflects the safeguarding of persons admitted to the home to prevent likely or potential harm to the individual and ensure that all staff are trained in this subject. Cavendish Residential Care Home Limited DS0000062449.V302963.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presented as comfortable, clean and well furnished. Service users benefit from the overall environment. The home was clean and hygienic. EVIDENCE: A tour of the home was undertaken and all communal areas were visited and several bedrooms were visited. The environment presents as a well furnished, comfortable and domestic in appearance and character. There were no odours present with the exception of one area, although this diminished later. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 19 On discussion with the proprietor, plans are being made for refurbishment of one main bathroom and the decorators will be in the home shortly to freshen up paintwork etc. Residents spoken to were happy with their rooms and the facilities in the home generally. Outside the grounds are adequately maintained with seating areas and attractive gardens. There were no obvious health and safety hazards noted. The laundry area was satisfactory and the arrangements for laundering of clothes appeared adequate. Service users spoken with did not express any concerns regarding the laundry service. The washing equipment being used was capable of meeting disinfection standards. Staff were observed to use protective equipment at appropriate times. Cavendish Residential Care Home Limited DS0000062449.V302963.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the numbers and skill mix of staff. Service users do not fully benefit from the ratio of staff that are appropriately trained. Recruitment practices need to improve. Staff training and development needs further work to ensure that all staff have the competencies required to meet all service users needs and to maintain a safe and supportive service. EVIDENCE: The ratios of staff to service users were determined using a method (Residential Forum calculation) recommended by the Department of Health. The staff group comprise of separate care and support staff, for example Cooks. The staff roster reflects the numbers of care staff assessed as being required by the home. Copies of the homes ‘working record’ were forwarded to the Commission shortly after the inspection. This indicated that the staff ratio assessment and actual deployment were met. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 21 Staff files were sampled to review recruitment practice, supervision and training. The files seen presented as rather muddled and some information was not readily available to ensure that recruitment procedures and practices were safe. The registered person must ensure that all of the required information relating to staff is available for inspection in accordance with regulatory requirements. Based upon the information available the home does not yet meet the standard of achieving at least 50 of care staff trained to National Vocational Qualification (NVQ) level 2 or equivalent. Some staff are working toward this qualification. The homes approach to staff training and development is in need of review. Whilst the sample of staff records (6) indicated that the sample group had received various training such as moving and handling (6), Medicine administration (3), continence management (3), diabetes (4), POVA (5) and four staff were following a course leading to either NVQ 2 or 3, the homes practice regarding medicine administration and safeguarding adults was poor. The registered person will need to ensure that staff possess the necessary knowledge, skills and experience to deliver the required level of informed care in accordance with the homes policies and procedures, National Minimum Standards, carers job descriptions and the homes Statement of Purpose. Whilst staff files indicated a list of training undertaken, there was no available assessment and training profile for each person to determine existing or identified training and development needs and requirements. The records were not able to identify why staff had undertaken particular types of training. Cavendish Residential Care Home Limited DS0000062449.V302963.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is no registered manager at the current time. The quality assurance system in the home is developing. Arrangements for the safe handling of residents personal allowance are satisfactory. Staff do not benefit from satisfactory supervisory arrangements. Service users do not fully benefit from the homes record keeping and policies and procedures. The health and safety practices in the home were satisfactory. EVIDENCE: Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 23 The Proprietor has developed an internal quality audit based on the Total Quality Management system. The audit was partially reviewed, as it is comprehensive, and was seen to be completed objectively and action plans written to address shortfalls. Mrs Hunt has sent out satisfaction questionnaires to healthcare professionals, residents and relatives and is awaiting the return of these. Results were subsequently sent to the Commission and these were positive but a copy of the questionnaire sent out was not available for inspection. Systems are in place for the safe handling of residents monies. A float is kept for each resident in a locked cupboard and checked daily by manager and staff. Three accounts were checked at random and found to be in good order with receipts and balances. The home holds monies for most of the residents and they can have access at any time. They discourage holding valuables and some residents have solicitors acting for them. One card and pin number needs to go back to solicitor as this is no longer needed by the home. This was discussed with the proprietor. Staff supervision was considered as part of this inspection. The six files sampled indicated that all carers had received a written annual appraisal although there were no ongoing supervision records available for inspection. This was discussed with Mrs Hunt, who stated that the records had been taken off site to be typed. It is unclear why this was deemed necessary. The forthcoming inspection will again review the supervisory records, which should be signed and dated by both the supervisee and supervisor. The registered person is recommended to refer to National Minimum Standards to ensure that the frequency and content of supervision is completed. Various records were inspected together with the homes policies and procedures. Record keeping was, in the main adequate although this report has highlighted the various departures from good accurate record keeping. The policies and procedures held within the home are comprehensive although some are in need of improvement, for example the safeguarding vulnerable adults procedure and the complaint procedure, both of which were found examples that the procedures and underpinning practice had not been followed to safeguard the best interests of the service user. The registered person will need to ensure that the practice element to the homes intended policy is understood and carried out by staff. Whilst there were no obvious health and safety concerns regarding the presenting premises, it was noted that the annual portable appliance checks for electrical equipment was not up to date (previous check 2.9.04). Other records such as fire safety were being maintained. The electrical installation certificate was dated 23.8.05, the last fire check visit was 24.1.06 and the last Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 24 visit by the environmental health service was 1.2.06 all of these being satisfactory. Accident records were checked and seen to be appropriately recorded and crossed referenced with daily notes in the care plan. Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 1 2 3 Cavendish Residential Care Home Limited DS0000062449.V302963.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 OP3 Regulation 14 Requirement The Registered Person must ensure that all prospective residents have a pre admission assessment to ensure that the home can meet their needs. The Registered Person must ensure that each person has a care plan reflective of all the assessed needs of service users. This is a second repeat requirement. The Registered Person must ensure that the care plans involve the resident or their representative, and that they are kept under review. The Registered Person must ensure that service users’ healthcare needs are monitored and attend to as required or directed by medical practitioners. This is a partial repeat requirement. The Registered Person must ensure the safe handling and administration of medication in the home. The Registered Person must ensure that service users receive DS0000062449.V302963.R01.S.doc Timescale for action 31/08/06 2 OP3 15 31/08/06 3 OP7 15 31/08/06 4 OP8 12, 13 31/08/06 5 OP9 13 (2) 31/08/06 6 OP10 12,13,15, 18,19,24 31/08/06 Cavendish Residential Care Home Limited Version 5.2 Page 27 7 OP14 8 OP16 9 OP18 10 OP28 11 OP29 12 OP30 13 OP31 14 OP33 dignified care at all times. This is a second 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. This is a repeat requirement. 22 The Registered Person must ensure that the procedure for managing complaints is followed. This is a repeat requirement. 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 and that the homes policy is up to date with current practice. This is a second repeat requirement. 18 The Registered Person must ensure that staff are trained to the requirements of National Minimum Standards. This is a repeat requirement. 19 The Registered Person must ensure that staff are recruited in accordance with regulatory requirements. This is a repeat requirement. 18 The Registered Person must ensure that there is an adequate training and development programme for staff. This is a second repeat requirement. 9 The Registered Person must ensure that a person registered as fit by CSCI undertakes daily ongoing management duties. This is a repeat requirement. 12, 24 The Registered Person must ensure that the home is run in the best interest of service users and continue to develop the quality assurance systems in the DS0000062449.V302963.R01.S.doc 31/08/06 31/08/06 31/08/06 30/09/06 31/08/06 30/09/06 31/08/06 31/08/06 Cavendish Residential Care Home Limited Version 5.2 Page 28 15 OP36 18 16 OP37 17 home. The Registered Person must ensure that care staff are appropriately supervised. This is a second repeat requirement. The Registered Person must ensure that records required by regulation are adequately maintained and available for inspection. This is a repeat requirement. 14/09/06 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cavendish Residential Care Home Limited DS0000062449.V302963.R01.S.doc Version 5.2 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.V302963.R01.S.doc Version 5.2 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. 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