Inspection on 14/06/07 for Cedarfoss House

This inspection was carried out on 14th June 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cedarfoss House 09/06/08

Cedarfoss House 22/06/06

Cedarfoss House 20/09/05

Cedarfoss House 14/10/04

Cedarfoss House 07/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Cedarfoss House 55 Hull Road Withernsea East Riding Of Yorks HU19 2EE Lead Inspector Diane Wilkinson Unannounced Inspection 14th June 2007 09:30 Cedarfoss House DS0000019658.V343901.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 Cedarfoss House DS0000019658.V343901.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. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedarfoss House Address 55 Hull Road Withernsea East Riding Of Yorks HU19 2EE 01964 614942 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) Willerfoss Homes Position Vacant Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2006 Brief Description of the Service: Cedarfoss House is a privately owned care home that is situated in the seaside town of Withernsea, on the East Yorkshire coast. The home is registered to provide care and accommodation for sixteen adults aged 18 - 65 years who have a learning disability. Accommodation is provided on two floors; private accommodation is situated on both floors and consists of six single bedrooms and five shared bedrooms. Communal accommodation is on the ground floor and consists of two lounges, a dining room and a conservatory. People using the service also have the benefit of a garden and patio area. The home does not have a passenger or stair lift to the first floor therefore service users with a physical disability would be accommodated on the ground floor. Service users have access to a range of local shops, services, transport and to the sea front. The weekly fees were recorded in the pre-inspection questionnaire; these are currently £344.50 per week. There is an additional charge for chiropody, hairdressing, toiletries and external activities. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 22nd June 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.00 am and ended at 4.30 pm. On the day of the site visit the inspector spoke with three residents, a senior carer, a manager for the organisation and the area manager. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The registered manager (who no longer works at the home) submitted information about the service in advance of the site visit by completing and returning a pre-inspection questionnaire. Survey forms were sent out prior to the inspection; four were returned from staff and one was returned from a GP. Comments from returned surveys and from discussions with service users, staff and others were mainly positive, for example, ‘I think the home is relaxed and happy. The residents and staff are supported by management and the proprietors’ and ‘the residents are all happy, loved and well cared for. The staff we have are all very caring and only want what is best for the residents’. Comments from surveys and from discussions on the day of the site visit will be included, anonymously, throughout the report. The inspector would like to thank service users, staff and the area manager for their assistance on the day of the site visit, and to everyone who completed a survey. What the service does well: Service users are supported to maintain links with family and friends. There is a good rapport between service users and staff, and staff were seen to encourage interaction between themselves and service users. Staff training and their understanding of policies and procedures on safeguarding adults protect service users from the potential to be abused. Service users are protected by the measures in place to control the risk of infection. Service users and staff said that the food prepared by the home is good. However, service users said that they would like more choice at breakfast time and at teatime. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Cedarfoss House DS0000019658.V343901.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 Cedarfoss House DS0000019658.V343901.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 judgement has been made using available evidence including a visit to this service. In most instances, service users are only admitted to the home following a full assessment that evidences that their current care needs can be met. EVIDENCE: The inspector examined admission and care planning records for a new service user; there was a needs assessment and a care plan in place. However, some sections of both of these documents had not been completed and this results in care planning documentation that is not a full reflection of the capabilities and needs of the person concerned. Two other care plans seen by the inspector included a full need’s assessment. None of the records seen included an individual’s strengths and needs. All relevant information about a service user should be held with current care planning documentation to assist staff in providing care that meets the individual’s assessed needs. Cedarfoss House DS0000019658.V343901.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. This judgement has been made using available evidence including a visit to this service. Care planning is not robust and does not provide an up to date record of a service user’s care needs. Staff encourage decision-making but supported risk taking is minimal; this restricts the lifestyle choices of service users. EVIDENCE: Care records for existing service users were seen to include a full assessment of needs that had been undertaken by the home, as well as a community care assessment/care plan produced by the commissioning local authority. These documents were used to inform the development of an individual care plan. Care plan development sheets have been devised to record meetings to discuss a service user’s individual care plan, although those seen had not been signed by service users or other named participants. Another document entitled, ‘Manager’s service user plan review’ has been developed but, again, this had not been completed. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 10 Records seen by the inspector evidenced that appropriate risk assessments had been undertaken, including those for moving and handling and those for the more specific needs of individuals. As a result of moving and handling assessments, service users are provided with any equipment they need, such as wheelchairs, hospital beds, pressure care mattresses and bed rails. Some specific medical needs of service users had been well recorded, and included instructions for staff on how to use equipment and the action to take in an emergency situation. Other information was not well recorded; an ‘annual record of seizures’ form for one service user was blank, although daily diary notes recorded that seizures had occurred. A health monitoring form records any contact with health care professionals including GP’s, Physiotherapists, appliance services and district nurses. The inspector observed in care plans that referrals are made to appropriate health care professionals on behalf of service users, such as consultants and nursing services. Care plans include bathing records and continence charts; these are not used consistently and so they are not a true record of the personal care assistance offered to service users. The inspector recommends that continence charts are only used when there is an identified need, and that continence and bathing charts are completed consistently to meet their purpose. Monthly updates/reviews of the care plan do take place and are recorded, but these are not consistent; this could result in the information recorded in care plans being out of date. Formal reviewing of care plans has improved; 6 monthly or annual reviews of the care plan take place and all interested persons are invited to attend. Records seen in care plans indicate that care managers are involved appropriately in assisting with decision making for service users. The inspector did not see any care plans that had been made available in a language and format that could assist service users to have a better understanding of the documentation. Due to the recent high turnover of staff, new staff are being employed by the home. This has resulted in some service users currently not having a dedicated key worker. The senior carer on duty informed the inspector that key workers will be allocated to those service users who do not currently have one and that every effort will be made to ensure that all service users are aware of who their key worker is. This will provide service users with a clear link with a member of staff working in the home. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 11 A service user told the inspector that they go out for a walk on their own. Apart from this, there was little information in care plans to evidence that service users are enabled to take responsible risks, within a risk management framework. The inspector did not see photographs in service user records examined. A photograph is needed to assist new staff with identifying service users, and in the event of a service user going missing from the home. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 12 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users’ nutritional needs are met and they are supported to make choices about their day-to-day lives. Service users are supported to maintain links with family and friends but there are only limited opportunities for taking part in age appropriate activities within the local community; this restricts a service user’s lifestyle. EVIDENCE: The pre-inspection questionnaire recorded that some service users attend the local day centre. However, staff said that none of the current service users attend. Some service users attend a social club – staff told the inspector that the club is not held every week, as there is sometimes difficulty in getting people to transport service users to and from the venue, and to run the club. Service users appear to be dependent on in-house activities to occupy Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 13 themselves during the day, and have little opportunity to meet people and make friends who do not have their disability. Staff support service users to maintain family links and friendships – care plans evidence that some service users spend time out of the home with their family, sometimes for a few days. However, visits from family and friends and visits out of the home are not always recorded on quality time/activity records. The inspector was informed by staff that there is a local leisure centre that offers activities suited to the needs of service users at the home but these are not currently accessed by service users. The inspector also found no evidence that service users utilise the beach or the sea in any way. Discussions with staff evidenced that they have lots of ideas about activities that could be based on their close vicinity to the coast, but none currently take place. The inspector observed on the day of the site visit that service users were supported to make decisions about their day to day lives, such as where to spend their day, when to eat meals and who to socialise with. One care plan seen by the inspector included specific information about the wishes of a service user regarding the time they wanted to get up in the mornings, and another included a statement from a service user recording that they understood why they could not be given a key to their bedroom, and that they agreed to this. None of the current service users have any responsibility for housekeeping tasks. The inspector observed information in one care plan about the involvement of an independent advocate; this evidences that the home are able to access this service on behalf of service users. Service users choose when to be alone or in company, and when to join in any activities; this was observed on the day of the site visit. Some staff present on the day of the site visit were quite new to the home, but all staff were seen to communicate well with service users and to encourage interaction. The inspector saw in care records examined that a sheet had been designed to record quality time and activities; some of these had been completed and others were blank. Daily diary sheets do record some activities, but again, this is not a full record of how service users have spent their day. Those quality time and activity sheets that had been completed recorded such things as, ‘watched movie, went to shop with member of staff, sat out in the sunshine, listened to music and played games’. There is little evidence that service users take part in activities within the local community. A member of staff recorded in a survey, ‘We have enough staff to meet daily needs, i.e. personal hygiene and in-house activities, but no staff to take them out’. A copy of the home’s weekly menus were included with the pre-inspection questionnaire. These evidence that there is always a choice of meal at lunchtimes but record that breakfast is the same every day and that the evening meal is always sandwiches. Service users told the inspector that they Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 14 would like some choice at these times, for example, a cooked breakfast or a choice of meal at teatime. On the day of the site visit, all service users had the same meal. A service user’s likes and dislikes regarding food are recorded in care plans. A member of staff stated in a survey, ‘the food is always presented nicely. They have a full cooked meal at least once a day. Choices are available’ and another described the food as, ‘Good home cooking’. The inspector observed that some service users chose not to have their lunch at 12.00 noon – they asked for it to be saved for them until later. These meals were wrapped in cling film and left on a work surface. The cook had prepared sandwiches for tea prior to lunchtime, as the dishwasher had broken and the cook had to wash up by hand after lunch and clean the kitchen before they left at 2.00 pm. The inspector contacted the Environmental Health Department and was advised that it would be preferable for the sandwiches to be prepared just before the cook leaves the home. They should be stored in the fridge until teatime. They also advised that cooked meals should be cooled quickly and then stored in the fridge until they are needed, and then thoroughly reheated. This information has been passed on to the home. Some service users have been weighed but this is spasmodic so serves little purpose regarding nutritional screening. The dining room is not homely or comfortable. Staff informed the inspector that a new carpet has been ordered for this room and that it has recently been redecorated, but the style of tables and chairs provided make the room look like a canteen rather than a dining room. This should be addressed by the registered provider. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and their health care needs are met. Medication procedures and staff training on the administration of medication are not robust and this could result in unsafe practices that put service users at risk. EVIDENCE: The inspector observed that staff respect the privacy of service users; service users were spoken to sensitively about personal care issues and staff knocked on bedroom, toilet and bathroom doors before entering. Care plans record preferred times for getting up, going to bed and choices regarding meals and other activities. There is evidence in care plans that specialist health and social care professionals are involved appropriately in the care of service users, such as physiotherapists and community learning disability nurses. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 16 There are currently no male staff working at the home. Although this has not posed a problem for current service users, it may be a problem for future service users; this situation should be reviewed every time new service users are admitted to the home. The registered persons should consider employing male staff so that service users have the choice of being assisted with personal care by a staff member of the same gender. Care plans included thorough details of a service user’s health care needs, and evidence that a service user’s health is monitored and potential problems are identified and dealt with at an early stage. There was no evidence in care plans that service users had an annual health check, although there is evidence that GP’s are called out as necessary, and that referrals are made to specialists when needed; the GP called to see five service users on the day of the site visit. The inspector observed the administration of medication on the day of the site visit. Medication is stored in a locked medication trolley that is fastened to the wall in the dining room; an alternative area should be found for storing the medication trolley, away from service user accommodation. Colour coded blister packs are provided by the Pharmacist. Medication administration records were examined and these were found to be accurate. None of the current service users self medicate and this is reflected in care plans. The inspector did not observe any practice involving ‘double dispensing’ of medication on the day of the site visit. The inspector examined the records for controlled drugs and the actual medication held by the home. Records had not been completed accurately – staff had recorded incorrect dates and times and this led to a lack of clarity in following the records. The correct number of controlled drugs remained but the records did not evidence that medication had been given at the correct time or on the correct day. More care must be taken with the recording of controlled drugs so that an accurate audit trail is available. There is a record of the staff that are trained to administer medication; some of these names were not accompanied by a sample signature. A member of staff that completed a survey recorded that they administer medication as part of their role; this person’s name was not on the list of staff recorded with medication administration records. There is evidence that some of these staff have undertaken in-house training rather than accredited medications training. All staff that administer medication must undertake accredited training to ensure the safety of service users. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 17 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints may have been dealt with in an open and transparent manner but there is no documentation to support this. Staff understand the policies and procedures in place on safeguarding adults and this offers service users protection from the potential to be abused. EVIDENCE: The inspector was informed by staff on duty that there is a complaints log in place, but this could not be found on the day of the site visit. The inspector examined quality assurance documentation; this includes a log sheet to record complaints made to the home. This sheet was blank, although the preinspection questionnaire records that two complaints have been received since the last inspection of the home and that these were substantiated. The preinspection questionnaire also records that these complaints were dealt with within 28 days. The inspector observed that there is a satisfactory complaints policy and procedure on display in the home. The training programme at the home evidences that most staff have undertaken training on safeguarding adults. Questionnaires returned by staff evidence that they have an understanding of the policies and procedures that are in place at the home on safeguarding adults, including whistle blowing. A Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 18 member of staff recorded, ‘we have an excellent whistle blowing policy. If we hear or see anything we do not like, there is always a manager on call day or night, and the proprietors are always available’. Since the last inspection of the home, a member of staff has been dismissed following allegations of abuse. This allegation was investigated appropriately by the registered providers and the CSCI were kept informed of the situation throughout. The person concerned was referred for consideration for inclusion in the Protection of Vulnerable Adults (POVA) register. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. Some areas of the home are not well maintained and some health and safety issues are not covered by risk assessments; this poses a risk to service users and staff. Service users are protected by measures in place to control the risk of infection. EVIDENCE: There is a maintenance programme in place and a handyman is employed to carry out day-to-day maintenance of the home; they were present on the day of the site visit. The kitchen is in a poor state of repair; kitchen units are shabby and difficult to keep clean, the dishwasher has broken and the cooker and the deep fat fryer are in need of repair. The refurbishment of the kitchen is recorded in the maintenance programme and the area manager informed the inspector that new kitchen appliances and units have been purchased and that they are now Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 20 waiting for workmen to commence this work. They expect this to be in August 2007. The area manager agreed that the new kitchen would be installed by the 31st August 2007. On the whole, the premises are safe, comfortable and clean, and provide sufficient light, heat and ventilation, although there is insufficient evidence that radiators are guarded to control the risk of burning for service users and that the need for window opening restrictors has been assessed. At the last inspection of the home requirements were made that risk assessments regarding the unguarded radiators and window opening restrictors should be undertaken; no evidence was found to support that these had been actioned. Furnishings, fittings, adaptations and equipment are good quality, with the exception of the dining room and kitchen (as previously recorded) and radiators. The premises are in keeping with the local community and the home offers access to local amenities, local transport and relevant support services. The premises meet the requirements of the local fire service and environmental health department. The premises were seen to be clean on the day of the site visit and there were no unpleasant odours. Laundry facilities are satisfactory and soiled laundry is not carried through areas where food is stored, prepared, cooked or eaten and facilities do not intrude on service users. The laundry room has two washbasins; one is used as a sluicing facility and the other is used by staff to wash their hands; the inspector recommends that a sign be placed over the washbasins to record their use. The training programme records that most staff have undertaken training on infection control and the inspector observed good hygiene practice being used by staff on the day of the site visit. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 21 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, 33, 34 and 35 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A well-trained staff team supports service users. Recruitment policies and practices do not fully protect service users from the potential to be abused. EVIDENCE: It is not clear in records held at the home how many staff have achieved a National Vocational Qualification (NVQ) at Level 2 or 3 in Care. Staff informed the inspector that enquiries have been made about the Learning Disability Award Framework (LDAF), but that this training has not yet commenced. The registered person should have a plan in place to ensure that 50 of care staff achieve NVQ Level 2 or 3 in Care and to evidence that staff have commenced LDAF training. The inspector observed that, although some staff on duty were newly recruited, all staff communicated well with service users and all were accessible and approachable. Records evidence that staff meetings used to take place on a regular basis but that these have ceased over the last year. This could result in a less than effective staff team. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 22 There has been a high turnover of staff recently; fourteen staff have left since the last inspection of the home. This has resulted in the home being ‘short staffed’ whilst new staff are recruited. A member of staff recorded in a survey, ‘Staff members are “burnt out” by doing lots of overtime for other members of staff who are off sick or have left, resulting in tiredness’. This could result in staff not caring for service users in an appropriate manner. The pre-inspection questionnaire records that agency staff are used to cover shift vacancies; this is usually about 48 hours per week. The registered person informed the inspector that the agencies used provide a regular group of staff for the home that are familiar with the needs of service users. As previously stated, there are currently no male members of care staff and this is something that should be considered when next recruiting new staff. The recruitment records for two new members of staff were examined by the inspector; these did not include copies of identification documents or a photograph of the person concerned. An application form is used by the home to record details of the prospective employee, and the area manager informed the inspector that written references and a satisfactory CRB check are obtained prior to staff commencing work. The area manager informed the inspector that, when staff need to be recruited quickly, a POVA first check is obtained. However, in the records seen by the inspector it was apparent that, in one instance, a POVA first check and written references were received after the person had commenced work at the home. The staff rota was examined by the inspector in an attempt to determine the first shift worked by new members of staff. It was noted that, when new employees undertake induction training, their name is added to the staff rota. It is not made clear when they are undertaking induction training and when they are covering a shift, so it is not possible to determine their first day at work. In two instances, the start date on contracts of employment did not match the first date recorded on the staff rota. The registered persons must ensure that all documentation is in place before staff commence work at the home. Evidence was seen in staff records that new staff receive a job description, a contract of employment and the code of conduct and practice as set by the General Social Care Council. The training programme evidences that staff undertake a variety of training programmes, and this is supported by information seen in individual staff records. Most staff have undertaken training on safeguarding adults, health and safety, fire safety, moving and handling, infection control and food hygiene. The training programme records the date that training was undertaken by staff and records the date that refresher training is needed. More specialised training has been undertaken by some staff, such as diabetes awareness and catheter care. Staff records evidence that Induction training Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 23 does take place for new staff but this is not clearly recorded; the dates that training took place and signatures of staff and trainers are not recorded. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 24 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. This judgement has been made using available evidence including a visit to this service. The quality assurance system is not fully operational; this results in service users and others not being able to affect the way in which the home is operated. The health, welfare and safety of service users are protected, with the exception of risk assessments regarding unguarded radiators, window opening restrictors and the lack of clarity regarding induction training. EVIDENCE: The registered manager of the home resigned from her post recently. The area manager wrote to the CSCI to inform us of the interim management arrangements for the home, which are considered to be satisfactory in the short term. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 25 The home has achieved QDS (the quality development scheme promoted by a local authority Social Services Department) Parts 1 and 2. There is a quality assurance calendar in place; this includes a complaints log, a record of surveys to be sent out/already sent out and a record of internal audits. A survey form was recently sent to health and social care professionals - as only two have been returned, the information has not yet been collated. Documentation was seen for surveys that are to be sent out to GP’s in the near future. Internal audits take place on such topics as care plans, daily reports, risk assessments and reviews. Any action taken as a result of collating information from these audits is recorded. Staff meetings used to take place on a regular basis but have lapsed over the last year. The pre-inspection questionnaire records that all policies and procedures were reviewed in April 2007 to ensure that they were still relevant and included the most up to date information. This is an effective quality assurance system but it needs to become fully operational so that service users and others can affect the way in which the home is operated. Health and safety documentation was examined by the inspector on the day of the site visit. This evidenced that all equipment has been serviced on a regular basis and that an annual test of the fire alarm system has been carried out, including emergency lighting and fire extinguishers. The electrical installation was tested in July 2006 and a portable appliance test was carried out in October 2006. There is a gas safety certificate in place until 5.5.06 – the area manager was certain that gas appliances were serviced again in May 2007 but no evidence could be found. She agreed to forward evidence of this to the CSCI but it has not yet been received. The home has produced a written statement of the policy, organisation and arrangements for maintaining safe working practices, including associated risk assessments. As previously recorded, there must be evidence that risk assessments have been undertaken in respect of unguarded radiators and window opening restrictors. There should be clear evidence that staff have undertaken training on health and safety topics as part of their induction training; this is not currently the case. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 26 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 2 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 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 3 X X 2 X Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 27 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 YA2 Regulation 14 (2) Requirement There must be a full needs assessment in place for all service users, including those that have respite care at the home. Care plans should be reviewed in-house consistently to ensure that the most up to date information is always available about service users. Recording of controlled drugs must be accurate to ensure an audit trail. The registered person must ensure that all staff that administer medication have undertaken accredited training. The kitchen is in a poor state of repair and must be refurbished by the date agreed on the day of the site visit. (The inspector was informed on the 28th August 2007 that this work has been completed). The registered person must ensure that risk assessments are in place for the unguarded radiators with high surface DS0000019658.V343901.R01.S.doc Timescale for action 31/08/07 2. YA6 15 31/08/07 3. 4. YA20 YA20 12 & 13 12 & 13 14/06/07 30/09/07 5. YA24 16 31/08/07 6. YA24 and YA42 13 (4)(c) 31/07/07 Cedarfoss House Version 5.2 Page 28 7. YA34 19 temperatures and control measures put in place. This is an ongoing requirement with a previous compliance date of 10/06/05 and 22/09/06. Two written references and a satisfactory CRB check (or POVA first check in exceptional circumstances) must be in place before staff commence work at the home. 14/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Refer to Standard YA2 YA6 YA9 YA9 YA12 YA13 YA15 YA17 YA17 YA18 YA33 Good Practice Recommendations The needs assessment should include details of a service user’s strengths and needs. Service users should be made aware of who their key worker is. Staff should enable service users to take responsible risks, within a risk management framework. Care plans should include a photograph of the service user concerned to assist new staff with identification and in the event of a service user going missing from the home. Service users should have the opportunity to take part in age/peer appropriate activities such as day centres or volunteer jobs. Service users should be encouraged and supported to become part of and participate in the local community. The registered person should ensure that an individual record of visits to service users, with details, should be kept. Furniture and fittings in the dining room should be improved to provide a congenial setting for service users to enjoy their meals. Nutritional screening should be consistent to become effective. The registered persons should consider employing male care staff so that service users have the choice of being DS0000019658.V343901.R01.S.doc Version 5.2 Page 29 Cedarfoss House 11. 12. 13. 14. 15. 16. 17. 18. 19. YA22 YA24 YA42 YA30 YA32 YA33 YA35 YA37 YA42 YA42 assisted with personal care by someone of the same gender. The complaints log should be available at all times. All complaints received and investigated by the home should be recorded in the complaints log. The registered person should ensure that a risk assessment is in place regarding the provision of window restrictors. Washbasins in the laundry room should be clearly identified as to their use. There should be a plan in place to record how 50 of care staff will achieve NVQ Level 2 or 3 in Care. Regular staff meetings should take place to promote an effective staff team. The registered person should make provision for staff to undertake LDAF training to support their achievement of NVQ qualifications. There should be a manager in place that is registered with the CSCI. Evidence that gas appliances/systems have been serviced should be sent to the CSCI. There should be evidence that induction training for all new staff includes training on health and safety topics. Cedarfoss House DS0000019658.V343901.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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