Inspection on 23/05/07 for Cedar Avenue

This inspection was carried out on 23rd May 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cedar Avenue 20/05/08

Cedar Avenue 11/10/06

Cedar Avenue 10/02/06

Cedar Avenue 18/07/05

Cedar Avenue 10/03/05

Cedar Avenue 29/06/04

Cedar Avenue 23/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Cedar Avenue 5 Cedar Avenue Edgerton Huddersfield West Yorkshire HD1 5QH Lead Inspector Cathy Howarth Unannounced Inspection 23rd May 2007 10:15 Cedar Avenue DS0000026335.V340899.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 Cedar Avenue DS0000026335.V340899.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. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedar Avenue Address 5 Cedar Avenue Edgerton Huddersfield West Yorkshire HD1 5QH 01484 530300 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) None United Response Ms Leanne Victoria Joseph Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2006 Brief Description of the Service: Cedar Avenue is registered to provide personal care and accommodation for up to four male and female adults aged 18-65 with a learning disability and physical disability. The registered provider is United Response. The purpose-built bungalow style accommodation is located in a residential setting within walking distance of Huddersfield town centre and local amenities. There is car parking available. The home is staffed twenty-four hours a day and there is one wakeful night staff member and one member of staff sleeping in on the premises. An on-call system is also in operation. The Commission were informed that as at 14.08.06 the weekly fee was £1662.86 per week. Information about the home in the form of a Service User’s Guide and Statement of Purpose, together with the most recent Commission for Social Care Inspection report are available at the home. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and was focused on key standards in particular those that were highlighted at the last inspection as requiring attention. The registered provider had provided an action plan outlining what they were doing to address the shortfalls in the service reported in the last report of the visit in October 2006. Before the inspection visit, the manager provided information about the service. Surveys were also sent to people living at Cedar Avenue, their families and health and social care professionals involved with them. People living at Cedar Avenue were supported by workers there to complete these. One relative returned a survey. The inspector visited the home over a two-day period and had the opportunity to spend time with people living there, talk with staff and the manager. The inspector would like to thank everyone who assisted for their warm welcome and cooperation with this inspection. What the service does well: What has improved since the last inspection? The home has had a new kitchen fitted and new flooring in the communal corridor. It was generally much cleaner, and tidy on this visit. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 6 The manager’s hours are now recorded on the rota. Equipment used for the movement of people in the home has been tested for safety. It was observed that fire escape routes were not obstructed during this visit. 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. The summary of this inspection report can be made available in other formats on request. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 7 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 Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 8 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): 2 People who use the service experience adequate quality outcomes in this area. This area was not assessed fully at this visit, as there have been no new admissions to the home since the last inspection. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: No new admissions have been made since the last inspection. The person who was admitted in 2006 has now settled into the home and progress has been made in ensuring that this person’s needs are clearly identified and addressed within the day-to-day running of the home. There are no plans for any new admissions in the future. Each person has a copy of the service user guide in their room which outlines what they can expect from life at Cedar Ave and is required to be given to each person using the service. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 9 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 and 9 People who use the service experience adequate quality outcomes in this area. Individuals’ choices and independence are promoted within the home and systems to ensure this is consistent, and that people’s choices can be accurately ascertained, are improving This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: This was an area that needed improvement at the last inspection. It is clear that some work has been done in this area to address some of the shortfalls. The home has implemented a short-term care plan system, which is working well to ensure that for example short-term health needs are adequately addressed. There is a plan to develop the support plans to be more detailed in how needs are to be addressed also. This is in its early stages but progress is promising. It is to be examined in more detail at the next visit. However the Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 10 person whose needs were not clearly addressed at the last visit has now got a support plan. Daily records have also been improved to provide more detail and ensure that important information is clearly recorded. This again is in its early stages but appeared to be working well so far. Risk assessments were found to be satisfactory for the people whose files were examined. A discussion was held with the manager in relation to one person who is able to self propel in their wheelchair but due to health and safety considerations for staff it has been proposed that they have a non propelling chair. This needs to be considered very carefully as it would have a significant impact on the individual’s independence and liberty. Every effort should be made to ensure that suitable alternatives are found to maintain this person’s independence. The manager and staff have recognised that there is a need to ensure that communication is given a high priority as the people living there have severe communication difficulties. Communication profiles are being developed for each individual and staff continue to develop their skills in using Makaton for example. These profiles are vital especially as there are significant numbers of staff who may need to be consistent in their approaches in order to prevent people from becoming frustrated when they cannot be understood. The inspector did observe some good practice in communication at the home, with staff being very patient in trying to make sure they understood what people living at the home wanted. Records and discussion with staff indicate that individuals receive sensitive and flexible personal support to maximise their privacy, dignity, independence and control over their lives. Staff were observed to offer people choice regarding food, drink, activity and where to spend time within the home. This was seen to be done in a way that promoted people’s independence, showing respect and maintaining people’s dignity. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 11 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 and 17 People who use the service experience good quality outcomes in this area. People are well supported to live their chosen lifestyles and their rights and choices are respected. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: From observations and examination of files and daily records it was clear that people living at Cedar Avenue do have good opportunities to live their chosen lifestyles. Staffing levels are generally good which enables people to receive the support they need to go out and do leisure activities they enjoy. Some people have regular day activities they go to but there was evidence of flexibility around evening and weekend activities. Individuals also have ‘negotiated support time’, where they may have specific support to do an activity they particularly enjoy. Around the home there was evidence of people’s interests being catered for with musical instruments, CD players and a Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 12 computer in the lounge area. Bedrooms also reflected the occupant’s interests. It was positive to note that people use public transport mainly for their activities and staff are able to support people to go by train to nearby cities such as Leeds and Manchester for shopping trips and music concerts for example. People are supported to maintain family and friend relationships. Each file had a list of family birthdays at the front to help staff support people to remember these occasions and to send cards. Staff said families are welcomed to the home and people are supported to visit their families wherever possible. Two of the people living at the home are of the Muslim faith. Staff support attendance at a local mosque and also ensure that halal meat is always available by buying this at a local halal butcher. One person also has a CD of a reading of the Koran, which they enjoy listening to in their bedroom. Although few of the staff team are Muslim or speak Punjabi, which is the first language of one person, staff have all attended training on cultural awareness and the benefits of this were evidenced in their practice in this area. Menus were seen and show a varied diet for all people living in the home who are able to eat food. One person has a gastric tube feed. People were seen choosing food and had a familiarity with the kitchen cupboard contents that indicated that they are routinely offered choices of different foods and could help themselves if they are able to do so. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 13 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 and 20 People who use the service experience adequate quality outcomes in this area. People receive good support with personal and health matters overall but some improvements are still needed to make sure that a consistent level of quality is provided. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: People who live at Cedar Avenue have access to health care services both within the home and in the local community. The majority of people who use services are able to choose their own GP and attend local dentists, opticians and other community services. Generally. Health needs are monitored and appropriate action and intervention taken. There have been improvements in the recording of information and advice given by other health professionals at appointments which is vital to ensure that all the staff are aware of what may need to be done for an individual following such an appointment. The home provides appropriate equipment for people’s individual personal care needs such as beds that can be raised or lowered and clinical waste disposal facilities. Staff have received training in moving and handling and using the Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 14 equipment available within the home to ensure that people are moved safely. The inspector observed that staff generally approached people in a person centred way when considering an individual’s personal care needs. This was echoed by one person’s family who also said they felt the team were “client centred”. Staff are aware of the need to treat individuals with respect and to consider dignity when delivering personal care, for example individuals were approached quietly and discreetly when there was a need for personal care and taken to a private place. There was evidence of other health professionals’ advice being sought and acted upon, when necessary, for example with reference to one person’s epilepsy. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. This has improved since the last inspection visit There were still however, some gaps in recording and on one of the days when the inspector visited the medicines for one person had been omitted. The staff on duty dealt this with promptly and efficiently. However it is important that consistent improvement is made within the team and maintained. The majority of staff have received training in handling medication but the high level of agency and relief staff used within the home may make it more difficult to achieve the consistency required to protect people living there. People who use the service are able to demonstrate their understanding of working towards improvement. The home has a training plan and intends to train its staff in health care to achieve accreditation. are happy with the way that most staff deliver their care and respect their dignity. Decisions on how personal care is delivered are not consistently recorded. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 15 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 and 23 People who use the service experience good quality outcomes in this area. There is a commitment to protecting people’s welfare and interests but some improvements are needed to better achieve this. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: The home’s complaints procedure is available in print and symbol format for service users who each have a copy. . The home’s complaints procedure is included in the home’s statement of purpose and service user’s guide. No complaints have been received by the home. One area for the registered provider to consider is in developing the use of advocates for the people who live at Cedar Avenue, as despite the fact that the procedure is available in alternative formats, for some people staff would be the main source of support for any complaint. This is not best practice and does not protect people’s interests. For example in the issue outlined earlier relating to the issue of whether one person can continue to use a self-propelling wheelchair. In this type of instance an advocate would be helpful to ensure that the person has independent support to express their interests. None of the people living at Cedar Ave are able to manage their money without support. Two samples of people’s monies were checked and reconciled with records held. Monies are stored securely. Receipts are kept and monies are Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 16 audited by two staff and double signed. None of the support staff can access people’s bank accounts. Staff who were on duty during this visit demonstrated a high level of awareness of issues relating to safeguarding the people who live at Cedar Ave. Staff receive training in this area, and particularly in relation to very vulnerable people. They are given guidance on whistleblowing procedures also. One concern, which the inspector had, was around with the high numbers of staff having intimate contact with people living at the home and the number of relief and agency staff involved. In addition to earlier concerns raised about consistency with this a vulnerable group of people, there are also concerns about them being potentially at risk. This is further highlighted by the fact that the home does not have details of vetting completed on agency staff (see staffing section). On a positive note most of the agency and relief workers are consistent but for one week in March twenty-nine different names appeared on the duty rota. The staffing situation is being addressed and vacancies being filled according to the manager but this needs to be done as a matter of urgency to avoid this kind of situation. Staff did indicate that they usually double up with agency workers initially to work alongside them when offering personal care, but clearly this may have an impact on people’s privacy and dignity and may not always be possible if staffing levels do not allow it. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 17 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 and 30 People who use the service experience adequate quality outcomes in this area. The environment at Cedar Avenue has improved but further work is needed to make it safe and comfortable for people living there. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: The house is a bungalow with a main communal lounge and a large kitchen. It is decorated in a homely way and there were examples of artwork by one person who lives there on some of the walls. The main corridor is rather bland however and would benefit from some ornamentation and/or signposting of rooms with objects of reference for some individuals who may benefit from this. The environment at Cedar Avenue has improved since the last inspection. A new kitchen has been fitted and new flooring has been put down in the main Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 18 corridor through the home. Also the shower room has been redecorated. However there are still some areas that need attention. One counter in the kitchen, which drops down to provide extra counter space, was broken and unhygienic, as it cannot be cleaned effectively. The laundry has been cleaned but has a large area of tiling missing. Again this cannot be cleaned effectively and is a risk for infection control, particularly as this is where the macerator for disposing of clinical waste is sited. Bathrooms were found to be generally clean but again there are repairs needed to fittings where exposed areas of wood and broken seals that could harbour infection. These need attention as a matter of priority. There is equipment such as protective gloves and aprons for use in personal care tasks for people living at the home. However the staff practice of carrying uncovered pads to the laundry room is not acceptable and some form of receptacle must be provided for this purpose. Other areas of the home were seen to be generally clean and tidy, including bedrooms. The newly decorated shower room, however, has not had the fittings replaced so the bathroom cabinet and other storage items were just on the floor. In the garden there was a new awning, which had been donated by a local charitable group. This could be a valuable addition to the outdoor space for people living there. This appeared to have been badly fitted however as it was leaning at a strange angle. The garden had a generally neglected air about it however and there was a mirror and an old bed, which need to be removed. Staff smoke in the garden but use an old plastic wipe box as an ashtray. As well as being unsightly this is not ideal in terms of safety. A metal ashtray with a lid would be preferable. Bedrooms are planned for redecoration in the coming months. Two bedrooms were seen and these were generally clean and tidy, although again there was evidence of items that needed putting on walls being left on the floor such as pictures. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 19 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 and 35 People who use the service experience adequate quality outcomes in this area. Staff working at the home are skilled and well supported but more permanent staff should be recruited to avoid the need for agency staff. Improvements are needed in vetting for agency staff. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: United Response has a clear and robust recruitment procedure for its own staff, which serves to protect the welfare of people living at the home. Two files for staff were seen and found to contain all the required information. Also the organisation repeats Criminal Records Bureau check every three years, which is good practice. However, the home does use a significant number of agency staff. No information was available for these staff, although the manager did state that CRB disclosures are seen when they first start. This is not recorded however and there was no information available from the agencies about any checks they have made on staff. The registered provider Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 20 must ensure they have satisfied themselves that the proper checks have been carried out on any staff working at the home. Staffing levels within the home are generally good with three staff on duty on most shifts as well as some sessional workers rostered to provide individual support for particular interests at certain times. Unfortunately because of vacancies, a significant number of shifts have to be covered with agency and relief staff, which raises problems with consistency and exposure of the people living there to a greater number of people supporting them than is desirable. This has been discussed earlier in this report in the section on Complaints and Protection. The manager did outline that there are plans in train to redeploy some staff within the company to address some of these issues in the coming months. United Response offer a good range of training for staff and staff were positive in their view that they are well equipped to meet the needs of people living at Cedar Ave. Training covers the range of needs of people living there including epilepsy, autism, cultural awareness and PEG feeding as well as basics such as moving people, food hygiene and protection of vulnerable adults. One area where the training is below standard however is in achievement of NVQ qualifications. At present only four staff have this qualification, which is 20 of the team. The minimum recommended standard is 50 . Staff supervision and team meetings are regular. On average staff receive supervision six weekly and it was positive to note that agency and relief staff who work regularly at the home also receive supervision from the manager. Staff reported that they find the manager supportive and approachable. Team meetings are held twice monthly and minutes are taken for the benefit of staff that cannot attend. These meetings are held at the office base rather than at the home so that people’s home is not disrupted. This is good practice. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 21 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 and 42 People who use the service experience adequate quality outcomes in this area. Management of the home is satisfactory and prospects for improvements seem good. Health and safety is generally well managed but some improvements are needed. This judgement has been made using a range of evidence including a visit to this service. EVIDENCE: The registered manager works at the home on a daily basis but shares her time between the home and the organisation’s office base nearby. Times when she is available are now on the rota however and staff reported that she is frequently at the home offering support and working alongside them. Ms Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 22 Joseph has not yet achieved her Registered Manager’s Award but is working towards this and said she aims to have it completed by the end of this year. The manager receives support from an area manager who offers regular supervision and carries out management visits to the home. These are sent to the Commission for Social Care Inspection as required in the last report to monitor improvements at the home. This requirement is repeated to continue this process. In February 2007 a survey of the aspirations and goals of people supported by the organisation was carried out, with help from families and other connected with the people who use the service. From this a plan has been developed to focus on improvements to be made to meet these aspirations, which fall broadly in the themes of relationships, community, work and communication. This has clearly driven some of the moves for change outlined earlier in this report to focus on improving support plans for people and developing communication profiles. This plan provides a detailed framework for how improvements are to be achieved and is a positive tool for change. It is in its early stages however, so implementation will need to be monitored closely and progress and outcomes for people living at the home need to be noted. The inspector will follow this progress with interest. Health and Safety was seen to be managed well overall. Regular safety checks are carried out and routine maintenance checks had been completed for lifting equipment used by people living at Cedar Ave. At the last inspection wheelchairs had been blocking escape routes. On this visit all routes were clear. Fire safety checks on the alarm system and equipment had been carried out. Fire drills have been carried out and recorded but there was no record of staff participating to ensure that all staff practice this at least twice a year, so that they are familiar with the procedure should a fire break out. A discussion was held with the manager about this and she agreed a system would be implemented to track staff participation in drills. Two people have hold- open devices fitted to their bedroom doors, which allow freedom of movement in and out but would close if the fire alarm were activated. Two other people, who are permanent wheelchair users, do not have such devices fitted to their doors. These people enjoy spending time in their rooms but both need to be monitored regularly to make sure they are safe. This can be difficult through a closed door so staff have to go in and disturb the occupants to check on them. Staff were also observed struggling to keep doors open to manoeuvre wheelchairs through. It was recommended that these doors also are fitted with the devices to improve choices and safety for the occupants and for the safety of staff supporting them. Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 23 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13(2) Requirement The medicines administration record must be completed whenever medication is administered to a service user, so that there are no gaps in recording. (Timescales of 17.11.04, 31.08.05 and 10.02.06 and 11.10.06 not met). Timescale for action 31/05/07 2. YA23 12(4), 13(6) 18(b) 3. YA24 The staffing establishment 31/07/07 should be adequate to ensure consistency and to protect the welfare and dignity of people living there. 23(2)(b)(d)(o) Maintenance work identified 31/07/07 in the body of this report must be addressed so that, both internally and externally, a safe, comfortable and homely environment is provided to service users (timescale of 22.12.06 partially met) 13(3) Appropriate repairs and replacements should be made to bathroom and laundry areas to ensure infection can DS0000026335.V340899.R01.S.doc 4 YA30 31/05/07 Cedar Avenue Version 5.2 Page 25 5 YA34 19 6 YA39 26 be controlled. Staff must not carry uncovered clinical waste through communal areas of the home. The registered provider must 15/06/07 demonstrate that they have taken steps to ensure that any agency staff working in the home have been thoroughly checked before starting work there. Management reports required 23/05/07 under Regulation 26 of The Care Homes Regulations 2001 must be supplied to the Commission. The registered person must implement a system to ensure that all staff working at the home participate in a drill at least twice a year so that they are familiar with the procedure should a fire break out. 30/06/07 7 YA42 23 (4) Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 26 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 YA22 YA24 Good Practice Recommendations The service should obtain the services of advocates, especially for those people who do not have close family to ensure that their welfare and choices are protected. The fixtures and fittings should be put back in the shower room. Pictures that people have chosen should be fixed to the wall in bedrooms so that people may enjoy them. The garden should be tidied up and unused furniture removed. 50 of care staff should achieve NVQ level 2 training or equivalent. The manager should complete the Registered Manager’s Award. The registered provider should consider fitting hold open devices to the two identified bedroom doors in order to improve safety and choices for the occupants and the health and safety of staff. 3. 4. 5. YA32 YA37 YA42 Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cedar Avenue DS0000026335.V340899.R01.S.doc Version 5.2 Page 28 - 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!