Inspection on 09/06/08 for Cedarfoss House

This inspection was carried out on 9th June 2008.

CSCI found this care home to be providing an Adequate service.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cedarfoss House 14/06/07

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 27/09/2008.

CARE HOME ADULTS 18-65 Cedarfoss House 55 Hull Road Withernsea East Riding Of Yorks HU19 2EE Lead Inspector Diane Wilkinson Key Unannounced Inspection 9th June 2008 10:30 Cedarfoss House DS0000019658.V366666.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.V366666.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.V366666.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) gaynor.saunders@willerfosshomes.co.uk Willerfoss Homes Manager awaiting registration Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2007 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 are accommodated on the ground floor. Service users have access to a range of local shops, services, transport and to the sea front. The manager told us that the current weekly accommodation fee is £350.00. There is an additional charge for chiropody, hairdressing, toiletries and external activities. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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 14th June 2007 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 10.30 am and ended at 4.30 pm. On the day of the site visit the inspector spoke on a one to one basis with three residents, a senior carer and a registered manager from the organisations ‘sister’ home, as well as chatting to other staff and a community nurse. Inspection of the premises and close examination of a range of documentation, including four care plans, were also undertaken. The newly appointed manager submitted information about the service in advance of the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA) form. Survey forms were sent out prior to the inspection; three were returned by residents, two were returned by relatives and one was returned by a care manager. Comments from discussions with people on the day of the site visit and from returned surveys were mainly positive, such as, ‘Every time we visited him we always found him happy and contented and although quite glad to be taken out for a break, very happy to return to those he calls his friends’ and ‘x is well looked after. He sees medical care on a regular basis and the home tries hard to improve his social life’. Other anonymised comments are included throughout the report. What the service does well: What has improved since the last inspection? Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 6 All residents have now been allocated a key worker and efforts have been made to explain the role of key workers to residents. Although no new permanent residents have been admitted to the home, there are arrangements in place to ensure that new residents (both respite care and permanent care) will be assessed prior to their admission. Responsible risk taking has led to residents being more involved in the local community. Complaints are now recorded in a complaints log. Some improvements have been made to decoration and furnishings in the dining room but it is still not homely. 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.V366666.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.V366666.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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The individual aspirations and needs of residents are assessed at the time of admission and reviewed appropriately. EVIDENCE: No new residents have been admitted to the home on a permanent basis. Staff told us that two people who were considering having respite care had been to look around the home. The manager had obtained a copy of the person’s care plan so that the assessment process could commence should they decide to have respite care at the home; neither had made this decision at the time of the site visit. We noted that care plans are being re-written and now include information on long-term and short-term goals and the strengths and needs of residents. Cedarfoss House DS0000019658.V366666.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 more robust but improvements still need to be made to ensure that care plans are up to date and to promote consistency. Staff support residents to take responsible risks but more effort is needed to support them in decision-making. EVIDENCE: We inspected three care plans and found that they are a good record of a person’s capabilities and needs, including information about any particular behaviours and advice on how these should be managed by staff. Care plans have been developed using the initial assessment undertaken by the home and assessment information obtained from health and social care professionals. There is evidence that residents, relatives and health and social care professionals are consulted about the content of individual care plans. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 10 Care plans include sensitive information about an individual’s life with advice for staff on how to handle this information or certain situations that could arise. We were told by the staff on duty that all residents now have a named key worker, and residents that we spoke to on the day of the site visit confirmed this. Efforts have been made to explain the role of a key worker to residents. The Annual Quality Assurance Assessment (AQAA) completed by the manager records that residents have a six monthly review. This is not always reflected in their records. Staff told us that annual formal reviews arranged by Social Services have taken place and records in all but one of the care files confirmed this. Monthly in-house reviews of residents’ care plans take place but some of the records seen on the day of the site visit indicated that these are not consistent; some were last reviewed in January 2008. This could result in care plans that are not up to date, and could result in residents not receiving appropriate care from staff. There are general risk assessments in place in some care plans but not in others – these include an assessment of a person’s moving and handling needs. Where they are in place, they have been completed thoroughly and have been reviewed. One care plan did not include a photograph of the resident; a photograph helps new staff to identify residents and assists the emergency services should someone go missing from the home. There are some individual risk assessments in place, for example, for the use of a mobility scooter. Care records evidence that residents are supported to make their own decisions within their capabilities. They are supported to manage their money appropriately and to purchase items or pay for leisure activities themselves. One resident attends a ‘Speak Up’ group that is organised by Mencap; they are sent a letter each month inviting them to the meeting and have to reply to let Mencap know whether or not they can attend. It would be encouraging to see more people attending such groups, or being given the opportunity to speak to someone independently. The manager has recorded in the AQAA that this is one of their aims for the coming year. Staff at the home now seem more confident about allowing residents to take ‘responsible risks’ and care records evidence this. Some residents go out unaccompanied and there are checks in place to ensure that residents are safe to do so. More varied activities are now taking place as a result of this, such as the use of a greenhouse. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are more involved in the local community and there are more opportunities for them to take part in chosen activities. People are supported to maintain contact with family and friends. Meal provision at the home is good. EVIDENCE: Since the last key inspection of the home there are opportunities for residents to take part in the local community. Residents told us about their trips out, and we noted that some residents take trips out unaccompanied, following a risk assessment process. It is evident that residents are supported to maintain any interests that they had before coming into the home or developed since; bedrooms are a reflection of a person’s hobbies and interests. One relative told us, ‘x is well looked after. He sees medical care on a regular basis and the home tries hard to improve his social life’. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 12 Some residents attend a day centre or social club, and staff told us about the enquiries they have been making to involve more residents in outside activities. Care plans now record how someone has spent their day, such as ‘took x to the shops’ ‘read book to x’, ‘picked flowers in the garden’ and ‘excited about their holiday – bought new clothes’. There is now a greenhouse and some of the residents are involved in gardening – they have some tomato plants and residents have planted some bedding plants, and have taken responsibility for watering them. Staff told us about a recent trip for residents to The Deep in Hull; five residents were accompanied by staff. Residents told us that they had enjoyed the trip and that they would love to go again; they were keen to show us the gifts they purchased whilst on this outing. Care plans evidence that staff support residents to remain in contact with family and friends, and staff are supportive of any friendships that form within the home. A relative told us, ‘Every time we visited him we always found him happy and contented and although quite glad to be taken out for a break, very happy to return to those he calls his friends’, and another relative said, ‘x telephones us when he needs to. We see him on a regular basis and he stays the night with us every two or three weeks’. We observed that staff interact well with residents and that there is friendly ‘banter’ between some residents and staff; we found this to be appropriate and to meet the individual wishes of residents. Residents told us that they are able to spend time alone or in company; this was observed on the day of the site visit. Care plans record a person’s preferred form of address and staff were seen and heard to use these. Independent advocates have been used by the home in the past where this involvement was felt to be helpful. On the day of the site visit we observed that there were two choices of main meal on offer - mince and Yorkshire puddings or sausages. There was also a choice of dessert and a choice of meals on the teatime menu. We asked if there is ever a cooked breakfast and were told that this was not on the menu. However, on some Saturdays residents have brunch in place of breakfast and lunch, and seem to enjoy this. We suggested that this should be discussed at the next residents meeting, as some residents may enjoy having a cooked breakfast, even if this was only on one day per week. We observed that staff offer appropriate assistance to residents. In the past residents have been weighed as part of nutritional screening, but this has lapsed. However, staff are aware of the need to monitor a person’s food and drink intake. A dietician has been involved with one resident and advice has been followed by staff on how to improve their diet. We observed Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 13 on the day of the site visit that fresh fruit was provided with the afternoon drink; this is good practice. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 14 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 do not currently ensure the safety of residents. 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, and residents confirmed this on the day of the site visit. 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. We observed that residents are able to choose their own clothes, hairstyle and makeup and that their appearance reflects their personality. There are currently no male staff working at the home but senior staff told us that they Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 15 had recently interviewed applicants for care worker posts, and one of these is a male. This has not created any concerns with current residents, and the cook and the handyperson are male so there is male company available for male residents should they want this. 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 such as dieticians and chiropodists when needed. Care plans record all contacts with health care professionals, including the reason for the contact and any outcome. The manager has recorded in the AQAA that all residents who have been prescribed medication have an annual medication review. 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; we discussed the provision of a medication cupboard in the dining room, which would provide unobtrusive and safe storage for medication and equipment used by district nurses. Staff agreed to discuss this with the registered provider. Colour coded blister packs are provided by the Pharmacist. Medication administration records were examined and we found that there were some gaps in recording. In addition to this, some medication that had been prescribed part of the way through the month had been recorded on medication administration records but not dated by staff. This could result in mistakes being made when administering medication. None of the current service users self medicate and this is reflected in care plans. None of the residents are currently prescribed controlled drugs but there are storage facilities available if they should be prescribed in the future. The current controlled drugs cabinet is not in an ideal place; it is in a cupboard in the bathroom that is also used for the storage of spare linen. Access to this could compromise the privacy of anyone using the bathroom. If a cupboard is built in the dining room, the controlled drugs cabinet should be moved to the cupboard so that all drugs are stored in the same area. Senior staff told us that they are monitoring the temperature of the medications cabinet as recommended by their Pharmacist. There is no medications fridge in place should the home be required to store antibiotics or other medications that needs to be stored at a low temperature. We were told that only senior carers administer medication at the home. There is no list of staff names kept with medication records to record the staff that have received training to enable them to safely administer medication. Staff have received training with the local pharmacist but it is not certain that this training is thorough enough to equip them to administer medication safely. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 16 The home has a contract with a local trainer who is arranging all staff training and will be maintaining associated records. This person is due to arrange medications training and will be presenting this to staff alongside the home’s pharmacist. Cedarfoss House DS0000019658.V366666.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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and relatives say that they know how to make a complaint although some improvements need to be made to the home’s policies and procedures. Staff have received training on safeguarding adults and tell us that they would use the policies and procedures in place at the home. EVIDENCE: The complaints procedure is displayed at the front door of the home. We examined the complaints log and noted that it records any complaints made, and the action taken. This would be improved if a record were also made of the response given to the complainant (including the date) and a note of whether or not they were satisfied with the outcome. There is no evidence that complaints are checked and monitored on a three monthly basis and this would also improve the procedure in place. All residents that completed a survey told us that they know who to talk to if they are unhappy and that they know how to make a complaint. Relatives told us that they knew how to make a complaint, and one relative said, ‘both my husband and I have never had to complain about the care given to our son’. Another relative said, ‘Up to now x has only had small problems but they have been handled with care’. There are appropriate policies and procedures in place on safeguarding adults and staff show awareness of how to act if they observe unacceptable behaviour Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 18 and the home’s whistle blowing policy. The whistle blowing policy is displayed in the home. Some staff told us that they had attended training on safeguarding adults this year, but it is not possible to determine how many staff have received appropriate training due to the lack of a training and development plan. This is to be addressed by the person who has been commissioned by the home to manage their training programme. We examined the monies held on behalf of residents and associated records and these were found to be accurate. We noted that money is handed to residents so that they can make purchases themselves. The system in place is complex and advice was given about how to implement a safe but simpler system to record financial transactions. Cedarfoss House DS0000019658.V366666.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. The home is well maintained but some communal areas require refurbishment to provide more attractive and comfortable accommodation for residents. The home is clean and staff follow good hygiene practices. EVIDENCE: There is a maintenance programme in place and a handyman is employed to carry out day-to-day maintenance of the home. The kitchen was in a poor state of repair when we last visited the home but this has now been fully refurbished. The dining room has been redecorated and a new carpet has been fitted, and this provides a more pleasant environment for residents. However, the furniture provided in this room is not domestic in nature and does not provide a homely atmosphere. The ‘music’ room is in need of redecoration and some of the furnishings and fittings in this room need to be replaced. Some of the furniture in the other lounge is damaged and should be replaced. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 20 The premises are safe, comfortable and clean, and provide sufficient light, heat and ventilation, although the risk of residents burning themselves on radiators remains. A notice has been placed above each radiator to alert people to the fact that they may be very hot. Some of the people living in the home are not able to understand the significance of such warnings and the safest option would be to fit radiator covers or change the radiators to those with a low temperature surface. 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. 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 were seen to be clean on the day of the site visit and there were no unpleasant odours. A relative told us in a survey, ‘The home is clean and tidy’ and we observed this to be the case on the day of the site visit. 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. At the last inspection we recommended that a sign be placed over the washbasins to record their use; this has not been actioned. Some staff have undertaken training on infection control and the inspector observed good hygiene practices being followed by staff on the day of the site visit. We noted that staff used a new pair of disposable gloves for each resident when administering medication; this is good practice. Cedarfoss House DS0000019658.V366666.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, 34 and 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care staff are recruited safely and are employed in sufficient numbers to care for the number of residents accommodated. Training opportunities for staff have improved but the lack of a training and development plan make it difficult to measure the training achievements and needs of the whole staff group. Some staff have commenced a qualification training programme. EVIDENCE: We saw information on the notice board on the day of the site visit that advertised various training opportunities to staff; basic food hygiene and moving and handling courses are planned for this month. Staff on duty told us that they had already attended some training courses this year, including safeguarding adults, diabetes and challenging behaviour. There is no training and development plan in place that records the training needs and achievements for the whole staff group so it is difficult to determine how many staff have attended relevant training programmes and if appropriate refresher training has been undertaken. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 22 Five care staff have commenced the Learning Disability Qualification (previously known as the Learning Disability Awards Framework); the training has been arranged for one day per month for three months, and staff have already attended the first of these sessions. This will help the home to achieve the target for 50 of care staff to have achieved NVQ Level 2 in Care. We examined the staff rota on the day of the site visit and this evidences that there are sufficient numbers of care staff employed to care for the number of residents accommodated at the home. A cook is employed Monday to Friday and the registered persons are in the process of employing a cook to work weekends. This would relieve care staff of having to prepare meals over the weekend and would reduce the risk of cross infection. Domestic staff are also employed. We observed that staffing levels are sufficient to allow some one to one time to be spent with residents, although one resident recorded in a survey, ‘if there was more staff we could do more activities’. We noted that staff work well as a team and that they communicate well with residents. A relative told us in a survey, ‘Staff seem to care for their charges and seem well on top of things. They all have a good sense of humour and a good rapport with x’. Staff meetings are taking place and staff supervision is now organised on a regular basis so that staff have the opportunity to have a one to one discussion with their manager. We examined the recruitment records for two new members of staff. These evidenced that two written references and a POVA first check had been obtained prior to them commencing work at the home. A CRB check was obtained as soon as possible after this date. It should be noted that POVA first checks should only be used in exceptional circumstances, not as a matter of course, and that staff must work under supervision until a satisfactory CRB check is received. There is no evidence that residents are involved in the selection process when employing new staff. Records state that new staff receive induction training but do not record what this training consists of. It is not possible to determine if this training meets Skills for Care specifications. As previously recorded, there is no training and development plan in place but the newly commissioned training organisation will be producing this shortly, in addition to arranging in-house and external training for staff. Individual staff records seen on the day of the site visit did not include copies of training certificates or an individual training record. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 23 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. There is a new manager in post who is experienced and qualified to run the home, and there is a satisfactory quality assurance system in place. There is insufficient evidence that residents are protected from the risk of harm by current health and safety systems and the arrangements for staff training. EVIDENCE: There is a new manager in post who is experienced and qualified to run the home. She has achieved the Registered Manager’s award and has had several years experience of working in various care settings. The manager is still shadowing senior carers and the registered manager of their ‘sister’ home until it is felt that she is able to take on full responsibility for managing Cedarfoss House; this is partly due to the delay in receiving her CRB clearance. The Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 24 manager provided us with the Annual Quality Assurance Assessment (AQAA) as requested; this recorded the improvements that they had made during the last year and the improvements they plan to make in the coming year. The manager plans to apply to the CSCI in due course for registration as the manager. Records at the home do not include a start date for the manager and two written references are not held on file; it is acknowledged that these may be held elsewhere. The home has achieved QDS (the quality development scheme promoted by the local authority Social Services Department) Parts 1 and 2 and there is a satisfactory quality assurance system in place at the home. This includes monthly quality audits, resident and relative surveys, information about resident reviews and the development of an annual business plan. Staff meetings are now held every three months and residents meetings are to be held monthly; two have already taken place. This gives residents and staff the opportunity to express an opinion about how the service is operated. We examined health and safety documentation held at the home, including fire records. These include records that evidence that a weekly in-house test of the fire alarm takes place and that fire drills are held periodically; we recommend that these increase to monthly. All other health and safety documentation was in place to evidence that systems and equipment has been serviced and maintained, including the fire alarm system, the gas system and equipment and mobility hoists. Risk assessments have been carried out for all safe working practice topics and accidents are recorded appropriately. There is currently insufficient evidence to show that all staff undertake health and safety training at the time of their induction training and then on an on-going basis. Water temperatures at outlets accessible to residents are checked on a daily basis and a test to detect the presence of Legionella in the water system has been carried out; none was found. As previously recorded, the arrangements in place to protect residents from the risk of burning themselves on unguarded radiators are not satisfactory, and there have been no risk assessments undertaken on the provision of window opening restrictors. See Environment. Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 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.V366666.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Risk assessments should be completed consistently and should be continually reviewed. Care plans should be reviewed both in-house and formally on a regular basis to ensure that the most up to date information is always available about service users. Previous timescale not met. The registered person must ensure that all staff that administer medication have undertaken appropriate training. Previous timescale of 30/09/07 not met. More care should be taken to ensure that recording on medication administration records are accurate. Timescale for action 09/06/08 2. YA6 15 09/06/08 3. YA20 12 & 13 01/09/08 4. YA20 12 & 13 09/06/08 Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA7 YA9 Good Practice Recommendations More effort should be made to encourage decision-making and to involve residents in independent advocacy groups. 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. Furniture 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. There must be a list of appropriately trained staff kept with medication records. This should include a sample of each staff member’s signature to enable medication records to be checked for authenticity and accuracy. Current medication storage arrangements compromise the privacy of residents and can easily be seen by visitors to the home. Storage arrangements should be improved. The complaints log should record the outcome of all complaints and the satisfaction (or otherwise) of the complainant. Complaints should be checked and monitored on a regular basis. The registered person should ensure that a risk assessment is in place regarding the provision of window restrictors. Some furniture and fittings need to be replaced and one of the communal lounge areas needs to be redecorated to improve the appearance and comfort of these areas. Washbasins in the laundry room should be clearly identified as to their use. POVA first checks should only be used in exceptional DS0000019658.V366666.R01.S.doc Version 5.2 Page 28 3. 4. 5. YA17 YA17 YA20 6. YA20 7. YA22 8. YA24 9. YA24 10. 11. YA30 YA34 Cedarfoss House circumstances, not routinely. Staff must work under supervision until a satisfactory CRB check is received. 12. 13. 14. YA34 YA37 YA42 Residents should be involved in the recruitment process when employing new staff. In due course the manager should apply to the CSCI for registration as the manager. There should be evidence that induction training for all new staff includes training on health and safety topics, and that refresher training takes place on a regular basis. The arrangements in place to protect residents from the risk of burning themselves on radiators are inadequate. 15. YA42 Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cedarfoss House DS0000019658.V366666.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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