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Inspection on 22/09/05 for Cedar Court

Also see our care home review for Cedar Court for more information

This inspection was carried out on 22nd September 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides personal and nursing care for people over the age of 65 years. Service users said they like living at the home, they feel safe there and there is always something to do. The home has a person specifically employed to organise activities for people who live there. There is a lot of information about different things that can be arranged to make sure everyone has enough mental and physical stimulation if they want it. One service user said she also liked to spend time listening to her radio in her room. The home serves the main meal at lunchtime and employs qualified people to work in the kitchen. Service users said the meals were plentiful and there was a good variety available. Staffing numbers on each shift are good, staff members said they usually had the proper numbers of staff to be able to look after the people who live at the home. If the numbers fell, the manager or most senior staff member tried their hardest to find another person to cover, so that service users didn`t have to wait to be cared for. Each staff member has the proper training when they start working at the home to make sure they are able to care for people properly without risking their health and safety.

What has improved since the last inspection?

The home was asked to improve four areas during the last inspection and to look at another three areas as changes they should make for good practice. Only two of the areas they had to change have been improved, plus one of the areas they were recommended to change. Records were seen to show the home now asks service users about their interests and life before they came in to the home. This means they can organise activities that mean something to service users and better help people keep up hobbies and interests. The family of one service user had sent a letter about that person`s likes, dislikes and personality and this gave good information about that person. The home is well maintained, clean and tidy. At the last inspection they were asked to make sure all areas were safe as the laundry door was kept open and open containers of washing powder and fabric softener were not stored safely. This has been done and the laundry door is now locked if there are no staff in the room. References taken up when a person applies to be employed at the home are clearer and show how that the applicant knows that person. This means the manager can check whether the reference is professional or personal.

What the care home could do better:

The home must improve ten areas and, as good practice, should change another eight areas that were found during this inspection. Two areas they must change have been carried over from the last inspection, as the timescale they were given to change has not been met. These are looking at care plans to make sure they are rewritten or updated if there are any changes to a persons care, and making sure the employment histories of new applicants are written in full, so that any breaks in work can be explained. If care plans are not looked at or rewritten when care changes, that person is at risk of not being looked after properly. If the dates between leaving one job and starting another are not written in full, the home has no information about the persons activity during this time, and cannot take all steps to make sure service users are safe. Other concerns about care records were that the home did not have copies of assessments done before people moved in to the home. Although information is sent from hospitals, a copy of the assessment done by the home must be kept. There have been two recent admissions outside the home`s categories of registration in spite of information provided by the hospital to indicate this. The home has been asked to inform the Commission for Social Care Inspection what they are going to do about this. Although healthcare professionals advice is requested, a doctor`s opinion is not always sought if people become unwell. While this is not always a problem, the reason for not doing so must be recorded. Care records should be dated fully and signed after each entry, to make sure there is an audit trail.Medication administration record sheets were kept properly, although a homely remedy was added to the bottom of one record, which means further doses could not be recorded. The name and address of the dispensing pharmacy must be recorded in the controlled drug register to keep an accurate record of where these drugs have come from and go to when they leave the home. One service user said she was not given a choice about how personal care was delivered. Staff members should ask people what their preference is before giving care, if they don`t already know. Some staff files did not contain all the required documentation. This leaves service users at risk as not all information about someone can be checked. Some staff members start their training before the Protection of Vulnerable Adults (PoVA) check has been returned, which is acceptable as long as that person has no contact with service users. It is recommended that the home does not employ any person until the PoVA First check has been returned at the very least. The home has records of checks done to make sure service users are safe. These include hot water temperatures, portable electrical testing (PAT) and fire alarm tests. However, not all of these records were available to be looked at or there were periods when the checks had not been carried out and certificates were not all available to show who had completed the work. This information must be kept and must be available to show the home complies with health and safety legislation. The manager is not registered with the Commission for Social Care Inspection. It is an offence under the Care Standards Act 2000. The provider has been asked to show how this is going to be resolved.

CARE HOMES FOR OLDER PEOPLE Cedar Court 37 New Road Whittlesey Cambridgeshire PE7 1SU Lead Inspector Lesley Richardson Unannounced Inspection 22nd September 2005 14:30 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 Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 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. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cedar Court Address 37 New Road Whittlesey Cambridgeshire PE7 1SU 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) 01733 350320 01733 350320 Cedar Court Care Limited Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (1), Physical disability of places over 65 years of age (24) Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 1 named female with physical disabilities under 65 years of age (PD) for the duration of her residency only 24 older people (OP) for the duration of condition 1 The maximum number of places not to exceed 25 Date of last inspection 17th May 2005 Brief Description of the Service: Cedar Court is a single storey purpose-built home that provides personal and nursing care and support for up to 25 people over the age of 65 years. It is owned by Cedar Court Care Ltd The building is situated in the market town of Whittlesey and is within reach of shops, pubs and other local amenities. Accommodation comprises 21 single bedrooms, all but two of which have en-suite facilities, and 2 double rooms, which also have en-suite facilities. There are a total of three day/quiet rooms and the home has bathing and toilet facilities, which are provided with aids to enable the needs of the residents to be met. The home has transport available to service users, including two wheelchair accessible vehicles, for visits into the community. Service users have access to a garden and patio area at the front of the building. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5½ hours and was carried out as an unannounced inspection on 22nd and 23rd September 2005. The inspection took place over two days because it was not possible to look at everything on the first day. This is the second inspection of this home for the 2005-2006 year. Three hours were spent examining records and documents and two and a half hours were spent with service users and staff. A brief tour of the building was also undertaken during this time. The manager was present during the inspection, although he is not the registered manager. Five people who were living at the home and four of the staff on duty were spoken to during the inspection. However, because some of the people living at the home had difficulty speaking, obtaining their views about everything was not always possible. What the service does well: What has improved since the last inspection? Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 6 The home was asked to improve four areas during the last inspection and to look at another three areas as changes they should make for good practice. Only two of the areas they had to change have been improved, plus one of the areas they were recommended to change. Records were seen to show the home now asks service users about their interests and life before they came in to the home. This means they can organise activities that mean something to service users and better help people keep up hobbies and interests. The family of one service user had sent a letter about that person’s likes, dislikes and personality and this gave good information about that person. The home is well maintained, clean and tidy. At the last inspection they were asked to make sure all areas were safe as the laundry door was kept open and open containers of washing powder and fabric softener were not stored safely. This has been done and the laundry door is now locked if there are no staff in the room. References taken up when a person applies to be employed at the home are clearer and show how that the applicant knows that person. This means the manager can check whether the reference is professional or personal. What they could do better: The home must improve ten areas and, as good practice, should change another eight areas that were found during this inspection. Two areas they must change have been carried over from the last inspection, as the timescale they were given to change has not been met. These are looking at care plans to make sure they are rewritten or updated if there are any changes to a persons care, and making sure the employment histories of new applicants are written in full, so that any breaks in work can be explained. If care plans are not looked at or rewritten when care changes, that person is at risk of not being looked after properly. If the dates between leaving one job and starting another are not written in full, the home has no information about the persons activity during this time, and cannot take all steps to make sure service users are safe. Other concerns about care records were that the home did not have copies of assessments done before people moved in to the home. Although information is sent from hospitals, a copy of the assessment done by the home must be kept. There have been two recent admissions outside the home’s categories of registration in spite of information provided by the hospital to indicate this. The home has been asked to inform the Commission for Social Care Inspection what they are going to do about this. Although healthcare professionals advice is requested, a doctor’s opinion is not always sought if people become unwell. While this is not always a problem, the reason for not doing so must be recorded. Care records should be dated fully and signed after each entry, to make sure there is an audit trail. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 7 Medication administration record sheets were kept properly, although a homely remedy was added to the bottom of one record, which means further doses could not be recorded. The name and address of the dispensing pharmacy must be recorded in the controlled drug register to keep an accurate record of where these drugs have come from and go to when they leave the home. One service user said she was not given a choice about how personal care was delivered. Staff members should ask people what their preference is before giving care, if they don’t already know. Some staff files did not contain all the required documentation. This leaves service users at risk as not all information about someone can be checked. Some staff members start their training before the Protection of Vulnerable Adults (PoVA) check has been returned, which is acceptable as long as that person has no contact with service users. It is recommended that the home does not employ any person until the PoVA First check has been returned at the very least. The home has records of checks done to make sure service users are safe. These include hot water temperatures, portable electrical testing (PAT) and fire alarm tests. However, not all of these records were available to be looked at or there were periods when the checks had not been carried out and certificates were not all available to show who had completed the work. This information must be kept and must be available to show the home complies with health and safety legislation. The manager is not registered with the Commission for Social Care Inspection. It is an offence under the Care Standards Act 2000. The provider has been asked to show how this is going to be resolved. 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. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home does not fully assess potential service users needs prior to admission, so cannot give assurances that care needs can be met. EVIDENCE: Information about prospective service users is obtained from health and social care sources, such as hospitals and social service departments, if that service user has had a recent admission to hospital or contact with social care professionals. The manager said assessments were undertaken by the home before service users were admitted to ensure that the person’s needs could be met. Records seen contained discharge information from hospital wards and assessments from social service departments, but these gave only limited information about service users needs. None of the three service user files looked at contained a pre-admission assessment completed by the home, although one service user had been admitted for respite care and had been at the home on previous occasions. The manager said he had visited the two service users who had been in hospital before they came to the home, but he was unable to locate the assessment undertaken at that time. Copies of preCedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 10 admission assessments of service user’s needs must be kept to ensure all aspects of those needs are met. The home had obtained information from the relative of one service user, which gave a good insight into that person’s personality, likes and dislikes. Two service users admitted since the last inspection from hospital had diagnosed conditions of dementia. The home is not registered to care for people with dementia and it is an offence under the Care Standards Act 2000 to breach the conditions of registration. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Limited progress has been made on improving arrangements to ensure that the personal and health care needs of service users are identified and met. These shortfalls have the potential to place service users at risk. EVIDENCE: Service users said they were happy at the home, and that the owners and staff would do anything for them. Care plans are written from the information obtained during the assessment period, and ensures assessed needs are met in the most appropriate way. Reviews of care plans should be undertaken at least once a month to ensure changes in care needs are recognised and the care needed to meet that need is properly planned for. Three service user files were seen to assess whether all identified needs had a plan to show how each was to be met. One file contained a detailed care plan that would enable staff members to properly care for that service user. The other two plans were well written but did not include information on how to manage all of the needs identified in pre-admission assessments received from Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 12 social service departments. These two plans had not been reviewed to show whether there had been any changes in care needs or not. This places these service users, whose level of need was high, at risk of not being cared for appropriately. Significantly, these include dementia needs for which the home is not registered. Risk assessments were completed in all of the service users records to help ascertain levels of need and plan appropriate care. However, not all of these risk assessments were reviewed monthly, even when the level of risk was highest. Not all entries in care records were dated or signed by the author of the entry. This is recommended as good practice to ensure an audit trail. Service users health needs are met either by the registered nurses on duty or healthcare professionals visiting the home. Referrals were seen for speech and language therapy and the dietician, but one service user’s care plan had not been updated to show advice and recommendations made by a visiting healthcare professional. Another service user’s records indicate medical advice was not obtained when that service user became unwell. There was no information in the service user’s records to show who made this decision, or why. The home uses a system of blister packs for medication administration recorded on Medication Administration Records (MAR). Records had been signed appropriately and indication was made for medication not administered, although the exact reason was not recorded on one service user’s MAR sheet. A homely remedy that had been given to one service user was recorded at the bottom of a MAR sheet. A new MAR sheet should be commenced if there is not enough room to write further medication on existing sheets. Medication is stored appropriately in a locked trolley, which is kept in a locked room when not in use. Controlled drugs are also stored and administration recorded appropriately. However, the name and address of the dispensing or receiving pharmacy is not written in the controlled drug register, which is required under the Misuse of Drugs (Safe Custody) Regulations 1973. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 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 Social activities provide stimulation and interest for people living in the home, and visits from relatives and friends ensure continued social contact. EVIDENCE: Service users said they are able to get up and go to bed when they want to, and they have a choice of meal every day. However, one service user said she was not given a choice on the day of inspection about how her personal care was delivered. She said she would have preferred not to have had a shower, but there was not enough hot water for a bath. The service user also said she could have told the care staff she didn’t like showers, but did not. Service users are able to choose what they wish to do during the day, and activities are also on offer. One person said she liked listening to the radio in her room as her eyesight was such that participating in many of the activities was difficult, although she often sat and listened to the conversations of other service users during this time. One service user said she had no choice about which room she moved in to, and although she was happy enough in a shared room, she would have chosen a single room if the choice had been there. Service users said they were able to have visitors at any time and for visits to be conducted anywhere in the home. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 14 The home has a dedicated activities co-ordinator who organises events for service users. She also collects information from service users about their preferences, previous social activities and life histories, although this information was not available for all service users. There is a copious amount of information about different activities for service users of the age range at the home. As activities take place, a list is kept of which service users attend and those that decline the opportunity. Service users said activities include mental stimulation games and quizzes, active games and opportunities and space for quieter activities, such as dominoes and cards. Because of the progress made following the last inspection the previous requirement has been met, although a recommendation is made regarding accurate identification of service user records. Service users said meals were plentiful with a good variety available. Service users have the opportunity of eating in the main dining room or in their own room if they prefer. Records of meals cooked are kept by kitchen staff, together with temperatures of hot food and a record of staff working in the kitchen. The home had a visit from the environmental health officer recently, which did not identify any major concerns and recommended annual visits. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 15 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 and 18 Systems are in place to ensure service users can comfortably raise concerns or complaints, and have these acted upon. EVIDENCE: Service users said they would be able to raise concerns if they were not happy about something and were able to do this with any member of staff. They also said they felt safe at the home. Staff members said concerns and complaints made to them would be passed immediately to the most senior member of staff on duty, as would any allegation of abuse. Staff files indicated some members had received protection from abuse training, but a training matrix was not available to show if all staff members had received this within 6 months of starting employment at the home. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 16 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, 25 and 26 The standard of the environment within the home is good, providing service users with an attractive and homely place to live. EVIDENCE: The home is well decorated and maintained, all areas are accessible to service users, with open communal spaces. It was clean, tidy and all areas were free from offensive odours. The risk of cross infection is reduced, as access to the laundry is away from the kitchen and eating areas. Access to the laundry has been limited to staff only, an automatic door closure is now in use and the door locked when staff are not present in the room. There were two areas in the home that could possibly place service users at risk, but at the time of inspection did not place service users at immediate risk. These are: • Pipes from radiators along the main corridor from the front to the rear of the building are not covered, although the radiators are covered, and when Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 17 • the radiators were turned full on during the inspection the pipes only became warm. Duvets and pillows are stored in a small space between service users wardrobes and the door to one shared room. As there is no hot water or heating pipes in this location the risk of fire is reduced. However, storing these items in this area is unsightly and should anything fall from between the space it could make entering or leaving the room difficult, which is both a fire and trip hazard. These issues were discussed with the manager and recommendations made regarding the need to either cover the pipe work or guarantee a low temperature. Storage of bedding should be in an enclosed space to reduce the risk of items falling into spaces used by service users. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 18 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, 29 and 30 There has been little improvement in the standard of vetting and recruitment practices since the last inspection. Required checks are not always carried out, potentially leaving service users at risk. EVIDENCE: The manager also acted as the registered nurse for the shift. He said there were five staff members on duty during the day. This was evident on the days of inspection. Staff members said staffing levels were good and the home tried very hard to get additional staff, either their own staff members or agency staff, if a sudden shortage occurred. New staff members complete an application form before being interviewed and have further checks to ensure they are suitable to work with vulnerable people. The files of two recently recruited staff members were looked at to check compliance with a requirement and recommendation made during the last inspection. The following areas were found not to have been fully explored or information obtained: • Completion of the employment history section in the application forms of both staff members was not adequate. One file had only the first name of the only previous employer listed, the other file had employment dates in months and years only and no explanation of gaps in employment, one of which was for 5 months. One of these staff members said she had previously worked in a care environment within the last 10 years, although there was nothing on her application form about this. The home was told Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 19 • • by the Commission for Social Care Inspection at the last inspection that they must obtain full employment histories and a written explanation of gaps in employment. One file did not contain a photograph of the employee. One file showed a PoVA First check had been returned after that person had started working at the home. However, the staff member said she had only completed training before the check had been returned and had not worked with service users. PoVA First checks are completed to ensure the applicants name has not been placed on the list of people deemed not suitable to work with vulnerable adults. Employment of a person in a position that requires contact with vulnerable adults, even if that contact does not occur before the check has been returned, places the home in a difficult position if they then need to take disciplinary action or terminate employment. It is therefore recommended that the home reconsiders current practice. All new staff members undergo induction training suitable for their position within the home. Induction training is conducted both by the home and through external sources, and includes all elements of health and safety mandatory training. Staff members said they are expected to attend training if this occurs on days off but thought they would be reimbursed for this. They also said they home contributes to transport costs that are incurred. Service user specific training is also available to all staff members; staff files show this includes behaviour and dementia training, protection of vulnerable adults, promoting continence, preventing pressure areas, death, dying and bereavement, confidentiality and food hygiene. Information resource files were seen in the nurses and carers room on a variety of subjects, including elements covered during induction training, continence, optical awareness, infection control, catheter information and a range of journal articles. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 20 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, 37 and 38 Records are not kept to a standard that ensures service users health and safety. EVIDENCE: The manager said there are plans to undertake a quality assurance survey to collect the views of service users, relatives and stakeholders in the community, but no firm dates for when this is to take place. The survey will also include audits of individual areas within the home, such as care records and the kitchen area. He was unable to locate previous survey results to see what points had been raised and whether the action plans require further work. The home does not look after service users money. If service users are unable to do so themselves, or do not wish to keep any money with them at the home, relatives may take this responsibility or it may be passed to social services to oversee or the home will seek an advocate for the service user. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 21 The home checks equipment and keeps records to safeguard service users welfare and interests. These include fridge and freezer temperatures, hot water temperatures, fire alarm tests, fire safety training, emergency light testing and accident records. Although, the manager said checks are completed, records were not available for everything that was done. These are listed below. • For the most part fire alarm testing was completed on a weekly basis. Although there were gaps in the recording showing occasional missed checks, there was also a gap between the 2nd and 4th week of August when no checks were completed. One service user was able to confirm that testing and practice fire drills took place. • Fire safety training records show staff members given this training during induction, but there were no training records for staff members undergoing updates of this training, although this has to be given on an annual basis. • A qualified electrician checks portable electrical equipment annually and this was shown by dated stickers on the plugs of checked pieces. The manager was not able to locate the certificate issued by the electrician. • Hot water temperatures are taken when service users have baths and showers, rather than the temperature of hot water straight from the tap. Records were available for the month of July 2005 and no temperature was recorded at above the recommended temperature of 43oc. However, records were not available for August and September 2005. These must be kept to ensure the safety of service users. The registered manager has left the home’s employment since the last inspection and the Responsible Individual is presently managing the home. As the Responsible Individual is approved by the Commission for Social Care Inspection, but not registered, the home must submit an application to register a manager. It is an offence under Section 11 of the Care Standards Act 2000 to manage a care home without being registered with the Commission for Social Care Inspection. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 18 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X 2 2 X 3 Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 23 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(1)(b), (2)(b) Requirement Timescale for action 23/09/05 2 *RQN 3 OP7 4 OP8 5 OP9 Accommodation must not be provided to a service user unless the registered person has obtained a copy of the assessment. CSA2000, Failure to comply with any Section 24 condition for the time being in force by virtue of this Part in respect of the establishment or agency, he shall be guilty of an offence. The home must only admit service users for whom they are registered. 15(2)(b), Care plans must be updated to (c) show how the home intends to meet changed needs. (Timescale of 31st July 2005 not met.) Failure to comply with requirements may lead to legal action being taken against the home. 13(1)(b) Arrangements must be made for service users to receive where necessary, treatment, advice and other services from an health care professional. 13(2) Name and address of the dispensing pharmacy must be recorded in the controlled drug DS0000063735.V250856.R01.S.doc 06/10/05 01/10/05 23/09/05 23/09/05 Cedar Court Version 5.0 Page 24 6 OP14 7 OP29 8 OP29 9 *RQN 10 OP37 register. The home must, as far as practicable, ascertain and take into account service users wishes and feelings. 19(4)(b) The home must obtain a full (i) employment history and a satisfactory written explanation of any gaps in employment. (Timescale of 30th June 2005 not met.) Failure to comply with requirements may lead to legal action being taken against the home. 19(4)(b) The registered person must not (i) employ any person to work at the care home unless the information and documents specified in Schedule 2 have been obtained. An application to register a manager must be submitted to the Commission for Social Care Inspection. CSA2000, Any person who carries on or Section 11 manages an establishment or agency of any description without being registered under this Part in respect of it shall be guilty of an offence. 17(3)(a), Records referred to in Schedule (b) 4 must be kept up to date and must available for inspection in the care home. 12(3) 01/10/05 23/09/05 23/09/05 06/10/05 01/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Service users care records should be signed and dated by the author of each entry to ensure an audit trail is available. DS0000063735.V250856.R01.S.doc Version 5.0 Page 25 Cedar Court 2 3 4 5 6 7 8 OP9 OP12 OP19 OP25 OP29 OP33 OP38 All medication administered to service users should be accurately documented on Medication Administration Record sheets. Service users details should be clearly written on all records pertaining to that person. The home should ensure storage of excess bed linen is not at risk of putting service users at risk. The home should ensure service users safety is not put at risk by exposed radiator pipes. New staff members should not start employment until satisfactory PoVA First checks are returned. The home should conduct a quality assurance survey as soon as possible as previous surveys are not available. The home should keep up to date records are available of checks undertaken to ensure the health and safety of service users. Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Cedar Court DS0000063735.V250856.R01.S.doc Version 5.0 Page 27 - 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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