CARE HOMES FOR OLDER PEOPLE
Cedar House 6 Dryden Road Enfield Middlesex EN1 2PP Lead Inspector
Tony Brennan Key Unannounced Inspection 20th April 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 Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Cedar House Address 6 Dryden Road Enfield Middlesex EN1 2PP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8360 3613 020 8360 3613 Cedar House Company Limited Mary Ezzat Mrs Sonja Anne Woods Care Home 17 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (16) Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One specified service user who is under 65 years of age and also has a physical disability may be accommodated in the home. The home must advise the registering authority at such time as the specified service user vacates the home. 1st November 2005 Date of last inspection Brief Description of the Service: Cedar House is a care home registered to provide residential care for seventeen elderly people of either sex, one of whom may have a mental health disorder. The home is a limited company owned by Dr G. Kattan and Ms Mary Ezzat. The home is located in a quiet residential area in Bush Hill Park about two minutes walk away from a train station. Enfield town centre is one stop by train and cafés, newsagents, restaurants and a post office are within two to three minutes walk from the home. The home has a large garden. The bedrooms are arranged on two floors. There are eleven single rooms and three double rooms. On the ground floor there is a lounge overlooking the garden and the dining room is at the front of the house. A room next to the kitchen is also used as a dining room. The table in this room is used for different purposes at different times. It is sometimes used for games, for writing and for eating. Another lounge is provided in the extension part of the building adjacent to the back garden. A table and chairs are available for service users to sit in the garden if they wish and if the weather permits. The home aims to provide care and support that is tailored to each service user’s needs. The home also seeks to provide supportive dementia care in a homely environment. The fees are between £450 and £600 a week. This report is available from the CSCI web site. Service users or members of the public may also contact the registered provider who will be able to provide them with copies of this report. Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection programme. The inspector also sought to confirm that the three areas for improvement identified at the last inspection were addressed. The inspection took place over one day. The registered person, Dr. Kattan, assisted the inspector for half of the inspection. Since the last inspection the manager had left Cedar House. A new manager will commence from the beginning of May 2006. The inspector spoke with eight people who live at Cedar House, two relatives and three staff. The inspector observed care practice and interaction between service users and staff. The inspector toured the building and examined a number of records relating to the care, health and safety and management of the home. The inspector would like to thank the registered person and staff who assisted him by answering questions about the running of the home. The inspector would also like to thank those people who live at the home who discussed their views of the service they receive. What the service does well: What has improved since the last inspection? What they could do better:
Eighteen areas for improvement are identified in this report. A person who lives at the home commented that an initial assessment had not been carried out of her needs. Initial assessments need to be carried out of all people coming to live in the home. Care plans did not contain detailed information on
Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 6 the needs of people living at the home and had not been reviewed. This resulted in gaps in the care provided to those living at the home. There were gaps in the records for medication received, administered and returned to the pharmacist. The area where medication is stored had a temperature above 25C. These issues put people living at the home at risk. People living at the home felt that insufficient activities were provided. A range of activities that met the needs and interests of those who live at the home should be provided. Bedroom doors left wedged open cause a potential risk in the event of fire. Discussions with staff and training records showed that training is required on fire and manual handling. A survey is needed of the views of those living at the home so that their views are sought of the quality of the service provided. Supervision records showed that staff had not received regular supervision to promote continuity in care. The fire alarm had not been tested and records showed that fire drills had not been carried out regularly. The safety of those who live at the home is compromised by this lack of adequate fire prevention precautions. Working practices had not been risk assessed to ensure that the home is a safe working environment. Two requirements made at the last inspection and two resulting from a complaint investigation have not yet been met and have been restated in this report, with a new timescale for compliance. In the ‘Timescale for Action’ column, the date in ordinary type relates to the timescale given at the last inspection. The date in bold type relates to the new timescale. Further information about unmet requirements can be found in the relevant section. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. The complaint investigation identified that medication was not checked in and this resulted in a person using the service not receiving her medication for a number of days. This was due to a breakdown in communication between senior staff and is not an acceptable practice. In order to protect vulnerable people receiving the service provided by Cedar House, the home was required to undertake the following actions in accordance with the Older People’s Regulations and Standards. The registered persons must ensure that all medication is recorded and administered. The registered persons must ensure that the administration of medication is monitored. The registered persons must ensure that the medication for service users receiving respite care is confirmed with their general practioner or their pharmacist. The registered persons should ensure that medication for those service users who receive respite care are not taken in pre filled dossett boxes.
Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 7 Although the remaining concerns raised in the complaint were not upheld, discussions with the manager highlighted a lack of initial assessment and planning to meet the needs of the service user. Therefore it was further required that: The registered persons must ensure that all potential service users coming for respite care are assessed before admission. The registered persons must ensure that the service users receiving respite care have a care plan that details the actions to meet their needs consistently. 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 House DS0000010650.V287856.R01.S.doc Version 5.1 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 House DS0000010650.V287856.R01.S.doc Version 5.1 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 quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users needs are not assessed prior to admission to the home. EVIDENCE: A service user who had recently been admitted to the home explained that she had not discussed her needs with staff at the home before her admission. She explained that she was diabetic and that staff sometimes have given her cake and then when she asked them if it was all right for her to eat it they “quickly take it away”. The inspector examined the file for this service user and found there was no initial assessment of her needs. Another service user also had no initial assessment. A recent complaint highlighted a lack of initial assessment of a service user’s needs. An immediate requirement was given to ensure that all service users receive an initial assessment prior to admission to the home. Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 The quality in this outcome areas is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users health, personal and social cares needs are not planned for and met Service users are not protected by safe procedures for handling medication. Service users’ right to privacy is respected. EVIDENCE: Service users said “sometimes staff don’t know what to do or how to help”. Care plans did not contain detailed information on the needs of service users. The care plan for one service user on how diabetes should be managed stated just to “observe” but did not outline possible signs or symptoms. A complaint investigation had highlighted the lack of care plans for service users who were receiving respite care. The inspector found that one service user who was receiving respite care had a care plan. The inspector saw that care plans had not been reviewed since February 2006. Service users spoken to said they had seen the GP and other medical professionals when needed. Records showed the medical needs are being met. Service users had been assessed for manual handling and risks of falls. Signage had been put in place to assist service users who have dementia to find their way around the home.
Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 11 The inspector found that there were gaps in the recording of medicines administered. This had been highlighted in a recent complaint investigation. An immediate requirement was issued that this issue be addressed. The inspector also found that the amounts of medication received were not recorded for all service users. Medication returned had not been recorded since February 2006. The service user on a respite stay’s medication had been checked and was in the original boxes. The area where medicines were stored had a temperature above 25 Centigrade. Discussion with staff and training records confirmed that staff had received medication training. A service user commented “staff offer a choice of food and don’t push you into anything”. The inspector observed care practice and found that staff offered service users choices (for example different foods). Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 12 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 15 The quality in this outcome areas is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are not provided with sufficient and varied activities to meet their needs. Service users are supported to maintain contact with relatives and other representatives of their choice. Service users are able to make choices about how they live in the home. Service users are provided with varied and balanced meals. EVIDENCE: A service user who had recently come to live at the Cedar House said that although staff had asked her about the kind of activities she liked, however, no activities had been provided. The inspector observed that no activities took place on the day of the inspection. The registered person told the inspector that there was an issue with the provision of “no or little activities”. The home has recently been registered to admit service users with dementia. The registered person felt that there would be a need to develop staff skills to deliver activities to these service users. Two friends of a service user spoken to told the inspector that they could visit whenever they wished and that they were always made welcome. They commented that the home was “very pleasant and staff were very welcoming”. A service user said that staff “let me get on with things as I like”. Staff spoken
Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 13 to understood the importance of supporting service users expression of their personal choices and preferences. Service users commented that the food was good and choices were provided. One service user commented that “the food is lovely and it suites me” The menu showed that varied and balanced meals were offered. Service users said they were consulted about the choices being offered. One service user commented that “the food is good and I told them what I like”. The inspector saw that meals were well presented and they were provided in a relaxed environment. Staff were observed assisting service users to eat in a sensitive and appropriate manner. Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 14 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 The quality in this outcome areas is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are confident that their complaints will be listened to, but complaints are not always taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Service users said that they felt confident in making their concerns known to staff. The complaints policy explained how to make a complaint and how it would be dealt with. One service user commented that on two occasions complaints hade been made, but the home had not responded. There was no complaints record to show the actions taken to resolve complaints. A recent complaint investigated by the home had been responded to within the required time scales. However, in this report a number of issues are highlighted that have not been addressed at this inspection. Service users said that they felt safe and could approach staff if they had any concerns regarding how they were treated. There were comprehensive policies on handling abuse and protection. Staff spoken to were clear about the signs of abuse and how suspected abuse should be handled. Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 15 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 The quality in this outcome areas is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users do not live in a safe and comfortable environment. The home is not clean and hygienic. This makes it an unsafe environment for service users. EVIDENCE: The inspector toured the building and found that the home was generally well decorated and in a good state of repair. However, there were a number of issues that need to be addressed to improve safety and comfort for service users. Bedroom doors (bedrooms 2, 3, 4) were found to be wedged open. This created a fire hazard in the event of fire. This was discussed with the registered person who agreed to put in place automatic closure devices so that service users who wish to have their bedroom doors open are safe in the event of a fire. Not all sinks in bathrooms and toilets had liquid soap and paper towels thus creating a risk of cross infection for service users and staff. Bedroom 11 was found to have an odour coming from the carpet. Staff spoken to understood how to prevent cross infection. Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 16 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 The quality in this outcome areas is adequate This judgement has been made from evidence gathered both during and before the visit to this service. There are sufficient staff to meet the needs of service users. Staff do not have the skills to meet all the needs of service users. Service users are safeguarded by the home’s recruitment procedures. EVIDENCE: The rota showed that the staffing level was maintained consistently. Service users spoken to said that staff were always available to meet their needs. The inspector examined four staff files and found that these contained all the required information. Discussion with staff and the training records showed that staff needed training on fire prevention and manual handling. Training records showed that 50 of staff have achieved the National Vocational Qualification in care at level 2. The registered person explained that all staff had a place on a dementia training course. Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 17 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): 33 35 36 38 The quality in this outcome areas is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have not been consulted about the quality of the service provided. Service users financial interests are protected by the home’s procedures. Staff are not appropriately supervised to ensure that the needs of service users are met. Service users and staff health and safety is not always promoted. EVIDENCE: The previous registered manager left Cedar House in February this year. The registered person explained that a new manager will be commencing work at the home in early May 06. The home has a system in place for the consultation of service users on the quality of the service. A service user spoken to commented, “They have not asked me what I think of this place.” The registered person explained that a survey had not been carried out. Relatives or social service departments manage service users’ money. The registered person explained that the home does not administer any service
Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 18 users money. The home does have the necessary procedure in place should it have to assist service users to manager their money. Some staff spoken to confirmed that they had supervision, but others had not had any supervision. The inspector examined supervision records that showed that only half of the staff group had received supervision, but there had not been any supervision taking place since February 06. Discussions with the registered person highlighted that there is still a need to put in place risk assessments for all working practices. The home has all the required policies on health and safety. The records for testing the fire alarms showed that the last weekly test took place on 23/1/06 and the last fire drill was eight months ago. Training had been provided on health and safety, first aid and infection control. Training is needed on manual handling and fire prevention as highlighted early in this report. All certificates relating to gas and electrical testing were in place and in date. Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 19 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 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 1 Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 20 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) Requirement The registered persons must ensure that all potential service users are assessed before admission to the home. (The time scale of 01/01/06 was not met). (Immediate Requirement given) The registered persons must ensure that care plans provide detailed information on how the needs of service users should be met. The registered persons must ensure that care plans are reviewed monthly. The registered persons must ensure that medicines administered are recorded. (The time scale of 01/01/06 was not met). (Immediate Requirement given) The registered persons must ensure that medication received is recorded. The registered persons must ensure that medication returned to the pharmacist is recorded
DS0000010650.V287856.R01.S.doc Timescale for action 20/04/06 2 OP7 15(1) 01/08/06 3 4 OP7 OP9 15(2)((b) 13(2) 01/06/06 20/04/06 5 6 OP9 OP9 13(2) 13(2) 01/06/06 01/06/06 Cedar House Version 5.1 Page 21 7 OP9 13(2) 8 OP12 16(2)(n) 9 OP16 17(2) 10 11 OP19 OP26 23(4)(a) 16 12 OP26 16(2)(k) 13 OP30 18(1) 14 OP33 24 15 OP36 18(2) 16 OP38 13 and signed for by the pharmacist. The registered persons must ensure that the temperature of the area where medication is stored remains below 25C. The registered persons must ensure that a range of activities is provided that meet the personal preferences and needs of service users. The registered persons must ensure that a record of complaints is maintained that details what the complaint concerned and what action was taken to resolve it. The registered persons must ensure that bedroom doors are not wedged open. The registered persons must ensure that staff are able to access liquid soap and paper towels when carrying out personal care. The registered persons must ensure that the carpet in bedroom 11 is cleaned or replaced. The registered persons must ensure that staff receive training on fire prevention and manual handling. The registered persons must ensure that a survey is carried out of service users and their representatives views of the quality of the service provided. The registered persons must ensure that staff have supervision six times a year and that this is recorded. (The time scale of 01/01/06 was not met). The responsible person must ensure that risk assessments are put in place for all working practices. (The time scale of 01/01/06 was not met).
DS0000010650.V287856.R01.S.doc 01/06/06 01/07/06 01/08/06 01/06/06 01/07/06 01/08/06 01/08/06 01/09/06 01/06/06 01/06/06 Cedar House Version 5.1 Page 22 17 18 OP38 OP38 23(4)(v) 23(4)(e) The registered persons must ensure that the fire alarms and systems are tested weekly. The registered persons must ensure that fire drills take place at least every six months. 01/06/06 01/06/06 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 Cedar House DS0000010650.V287856.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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