Inspection on 14/08/06 for The Cedars

This inspection was carried out on 14th August 2006.

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

Other inspections for this house

The Cedars 16/06/08

The Cedars 04/07/07

The Cedars 08/02/06

The Cedars 12/08/05

The Cedars 08/03/05

The Cedars 21/07/04

The Cedars 05/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Cedars 144 London Road Gloucester Glos GL2 0RS Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 14 and 22nd August 2006 09:30 th The Cedars DS0000016601.V301048.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 The Cedars DS0000016601.V301048.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. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars Address 144 London Road Gloucester Glos GL2 0RS 01452 500899 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) Cotswold Care Services Limited To be appointed. Care Home 9 Category(ies) of Learning disability (9) registration, with number of places The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: The Cedars provides care and accommodation for up to nine adults with learning disabilities. The home is owned and run by Cotswold Care Services Limited, which is a subsidiary of the Craegmoor Healthcare group. It is a large three-storey detached Victorian house about a mile from the centre of Gloucester. All people living at the home have single bedrooms. Communal areas include the kitchen, dining room and lounge. There is also an enclosed rear garden and an annexe, which accommodates the day-centre. This is used by people living at the Cedars and by people living at other local Craegmoor homes. The fees at the home range from £957 to £1,228 per week. A summary of the Statement of Purpose is displayed in the hall. Each person living at the home has a copy of the Statement of Purpose and Service User Guide in their personal files. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in August 2006 and included two visits to the home on 14th August and 22nd August. The acting manager was present for part of these visits. Discussions were held with the area manager and five staff. The care of three people living at the home was observed and four people were spoken to. Comment cards were received from relatives and visitors. A pre-inspection questionnaire was returned prior to the visit. A selection of records were also examined these included service users’ plans, staff files, quality assurance and health and safety records. What the service does well: What has improved since the last inspection? What they could do better: There needs to be greater consistency in record keeping, the monitoring and evaluation of care plans. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 6 When risk assessments are put in place to reduce risks to people living at the home staff must follow these assessments to minimise the risk of harm. Medication administration systems need to be improved to safeguard people living at the home. Outstanding environmental improvements such as relocating the laundry and relaying the patio are due for refurbishment. An action plan must be submitted detailing the schedule of works. Training needs to be provided for staff in areas such as epilepsy and diabetes. Fire doors have been fitted although some have been highlighted as needing attention. This must be actioned promptly. 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 Cedars DS0000016601.V301048.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 The Cedars DS0000016601.V301048.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An assessment of the needs and wishes of prospective service users is completed to ensure that the home is able to meet their needs. EVIDENCE: The home has an admissions policy and procedure that includes obtaining an assessment from the placing authority and completing an assessment by the home’s manager. The acting manager confirmed that visits to the home would also be arranged. The home presently has two vacancies. No new admissions are presently being processed. No one has been admitted to the home in the past twelve months. The Cedars DS0000016601.V301048.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning in the home is generally good promoting the development of skills and independence. Improvements in record keeping will ensure that staff are provided with the information they need to satisfactorily meet the needs of people. People living at the home are provided with support and assistance to make decisions about their lifestyles. Risk assessments encourage and support people living at the home to challenge and deal with problem areas in their lives. EVIDENCE: The care of three people living at the home was case tracked. This included observing their care, examining their care plans, medication and financial records, talking to staff about the care provided and looking at their rooms. All had an ‘outcome based evaluation and assessment’ which determines their level of staffing needs. The home uses Essential Lifestyle Plans’ which include The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 10 a personal assessment of need from which care plans are developed. This assessment covers the physical, intellectual, emotional and social needs of the person. Two of the plans were reviewed in March 2006 and are being regularly evaluated by key workers. These commented on progress being made. This is good practice. The third plan was due to be reviewed in August 2006. The evaluation sheets for the care plans for this person were not being completed. This should be done. A range of monitoring charts are being used in conjunction with care plans. For instance dietary records are being maintained for a person with diabetes and a behaviour chart is being kept for a person monitoring incidences of challenging behaviour. ABC charts are also kept to describe incidents of challenging behaviour and the use of physical intervention or diffusion and distraction. Discussions with staff confirmed their understanding and awareness of the needs of the people they support. Some felt that they had not been given sufficient guidance in response to recent changes in the behaviour of one person. However at the time of the inspection a protocol for managing challenging behaviour and use of ‘as required’ medication had been put in place after consultation with members of the local Community Learning Disability Team. Further appointments with the team are being arranged. There was also evidence that a risk assessment had been put in place as a result of an incident in a car. This stated that the person living at the home must sit in the back of the mini bus and be supported by two staff. On the day of the first visit this person was offered a lift in a car with two members of staff. When questioned the acting manager said that this was appropriate. The risk assessment must reflect this. Risk assessments have been put in place as a result of hazards identified in care plans and are being regularly reviewed. A risk assessment for a person with epilepsy must also include guidance for staff about the support needed when the person is bathing. Any restrictions to freedom of choice or movement such as the use of keypads to the kitchen and keys to individual’s rooms are recorded in care plans. There was evidence that some people living at the home have signed their plans. One person has a monitor in their room to keep a check on them in case of epileptic seizure. There should be a consent form in place for the use of this and a protocol for staff indicating how and when it is to be used. Staff were observed checking personal finances. This is completed by two staff at handover. Receipts are kept for all items of expenditure and any withdrawals are noted on a petty cash receipt. The Cedars DS0000016601.V301048.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home have some access to their local community and other facilities providing opportunities for them to be engaged in appropriate activities. This could be further improved. People living at the home are supported to maintain contact with family and friends respecting their personal relationships. There are some opportunities for people living at the home to be involved in activities of daily living promoting their independence. Freshly cooked meals are produced which provide a nutritional and balanced diet. EVIDENCE: Each person has an activity schedule indicating a range of activities from horse riding, swimming to aromatherapy, aerobics and dance. Staff confirmed that wherever possible these are put in place. They have access to a day care The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 12 centre at the home that has two members of staff in addition to care staff. Some people also attend a local college in term time. Daily diaries for the last six weeks confirmed people had access to swimming, aromatherapy sessions, shopping and taken day trips to places of interest. For some people their daily notes indicated a lot of ‘pottering’ around the garden and staff confirmed that for some this was the case. Relatives also commented that there had been a reduction in the level of activities available. This will be monitored. Holidays for people living at the home coincided with this inspection. Over a period of two weeks two groups went away for a five-day break to the seaside. During the visit people were observed being supported to access a local shop. One person discussed with staff when they could return a book to the library. Staff also discussed taking people to the local cinema. Daily notes indicated that people are involved in shopping for the house as well as cleaning, clearing away and cooking. One person said that they liked to help with the cooking. Staff confirmed that they support people to prepare and help cook the evening meal. Daily records confirm that people have regular access to friends and relatives either by telephone, visiting or meeting them or a visit to the home. Contact records are also kept on individual files. A person was observed calling a relative by telephone. People living at the home were observed having flexible routines. One person decided to stay in bed late and daily notes confirm different times for people going to bed. People were observed choosing where to spend their time and with whom. As mentioned any restrictions to access such as the kitchen are recorded in care plans. Some people use the kitchen with staff support. The menu is displayed in the kitchen and is planned on a three-week roll over programme. A range of freshly prepared and frozen meals are available. Some shopping had been purchased on the day of the first visit. The fridge was well stocked with fresh vegetables and there was a large bowl of fresh fruit. Additional records are kept of vegetables provided with the evening meal. Individual daily records keep a record of what food each person has eaten. This is not easy to detect and requires reading through the text. It is advisable that a system is put in place for easy recording of food eaten by people living at the home. Food stored in the fridge was marked with the date of opening. Plans for one person indicate that they like spicy foods and daily notes confirm that curries are provided. A person also has an eating disorder and there was evidence that their diet and weight are being monitored. Staff discussed healthy eating options with this person during the visit. They happily accepted a hot drink and fresh fruit. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff do not have access to sufficient information about the support people living at the home require to meet their healthcare needs. People living at the home have access to a range of healthcare professionals. Medication administration systems need to be improved to safeguard people living at the home from possible harm. EVIDENCE: Each Essential Lifestyle Plan includes a list of likes and dislikes and these are further explored in care plans. The cultural background and gender of staff reflects that of people living at the home. There was evidence that a speech therapist is now working with the staff to support people who have limited verbal expression. Training for staff in makaton is planned for later in the year. A communication profile was included in care plans for people unable to express their needs verbally. Information is displayed in the home about local advocacy organisations. The acting manager stated that no one at the home presently has an advocate. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 14 People living at the home have access to a range of healthcare professionals. A summary sheet records these appointments including Doctors, Dentists and Chiropodists. There was evidence in daily notes and protocols of prompt referral to the Doctor when needed. The local Community Learning Disability Team also provide support to staff. One person who has diabetes also has regular contact with their Diabetic Nurse. A protocol in place for this person indicates that if the blood sugar level test is outside normal parameters then the Nurse or Manager of the home is to be contacted. This protocol needs to be expanded further to give staff specific guidance about what they should be looking for and what immediate action to take if these people are not available. Staff must also have access to training about Diabetes. A person living at the home had recently been to hospital and the acting manager confirmed that they had offered to remain with the person during their stay but the hospital had indicated that they could manage. Regular visits were shared with the parents and family of the person. It is recommended that the home access copies of the local Health Action Plan which would complement the records they use but provide a hand held record which could be taken to appointments and to hospital if needed. The home has a monitored dosage system for the dispensing of medication. A member of staff was observed giving medication to people living at the home. They took the medication to the person then left the tablets with them whilst the person was finishing their meal. This left the medication with the person unsupervised by staff. They then returned to check that the medication had been taken before signing the administration record. Staff must be able to confirm that the person took the medication – it may have been dropped, taken by another person or disposed of. There were some handwritten entries on the administration record some had been signed and countersigned by staff but other entries had not. A member of staff explained that they have requested that the pharmacy update the administration record to include these medications. Until such time as this is done handwritten entries must be signed and preferably countersigned. One person’s care plan indicated that they are allergic to penicillin. This was not completed on the record. This must be done. A signature list is in place confirming staff initials. Staff confirmed that they complete training in the administration of medication. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An effective complaints procedure is in place which responds quickly to concerns raised by people living at the home and their representatives. A knowledgeable staff team and policies and procedures protect people living at the home from possible abuse. EVIDENCE: The home has a complaints policy and procedure the summary of which is displayed in the hall. People living at the home have access to the complaints procedure produced in text and picture as part of the Service User Guide. Comment cards returned from relatives indicated that they are aware of the complaints procedure but have not had cause to use it. The home has received one complaint that was investigated by a manager from another home and was substantiated. After discussion with the acting manager it was unclear whether another incident had been reported to the Commission involving another complaint. The acting manager said that all information concerning the investigation would be forwarded to the Commission. Since the last inspection training has been provided for staff in the Protection of Vulnerable Adults. Those staff spoken with appeared to have a good understanding of abuse and their role in preventing and/or reporting suspected poor practice or abuse. All staff complete training in the management of challenging behaviour (CPI or Crisis Prevention) and further courses are booked for later this year. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 16 Financial records were examined for a person who uses a bank card. Full bank statements are backed up by summary sheets and receipts kept at the home. The acting manager was advised to keep the cash withdrawal receipts with the bank statement and to initial the statement as these are checked each month. Savings accounts where the manager was appointee have been closed and all savings deposited in accounts opened by Craegmoor. Regular statements are expected from the organisation each month. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A homely and welcoming environment is let down by inadequate cleaning resources and outstanding environmental work which poses a hazard to people living at the home. EVIDENCE: There are a number of outstanding requirements that were issued at previous inspections in relation to the environment: • • • • The first floor shower facility is to be made safe for independent use and must be appropriate for the needs of the person using it the patio outside the lounge needs levelling and making safe artex in Room 8 needs removing or covering requirements issued by Environmental Health in relation to the laundry must be actioned. The acting manager and maintenance person confirmed that funding has been secured in this year’s budget for these improvements and that quotations have been obtained from builders. An action plan must be sent to the Commission detailing when these works are scheduled to begin. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 18 A walk around the environment was completed with the maintenance person including five bedrooms. Carpets in the communal areas including the lounge and hallway need replacing. In several places the carpet is torn and is considerably stained. Staff confirmed that the carpets are regularly cleaned. The carpet in Room 5 is also torn along the seam where two carpets are joined this needs attending to. The paintwork throughout the home is well maintained. At the time of the visit one bedroom was being redecorated. The unsuitability of the laundry has been under discussion for a number of years. The acting manager confirmed that there are plans to site this in a room on the ground floor. On the day of the visit the room was damp due to problems with the tumble dryer. It is recommended that sheets stored in the laundry are stored elsewhere to ensure their freshness and that they are dry. Colour coded mops and personal protective equipment are provided. COSHH data sheets are in place and hazardous products stored securely. Infection Control training has been provided for staff. Staff were observed cleaning the home as part of their duties. The home formerly had a cleaner working part time over five days a week. It was noted that the kitchen floor was sticky underfoot and some parts of the home although tidy did not look clean. The lid was also missing from the bin in the kitchen creating infection control issues. Staff indicated that they are able to keep on top of the basics but not able to do periodic cleaning. They did say that they would be taking the opportunity whilst people were on holiday to spring clean individual bedrooms. The acting manager must consider how this can be effectively managed. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team have access to an NVQ programme providing them with the competences and skills required to meet the needs of people living at the home. The standard of vetting and recruitment practices has improved slightly but people living at the home are still potentially at risk. Further improvements need to be made to reduce the possibility of harm. By providing training specific to the conditions of people living at the home the staff team will the knowledge they require to meet their needs. EVIDENCE: Staff on duty during the visits appeared to be approachable and accessible to people living at the home. They confirmed that a NVQ programme is running with seven people working towards either Level 2 or 3 awards. Two people have completed awards in Level 2 and 3. There was information available to staff about specific conditions of people living at the home and they confirmed that they have access to this. Staff need to have access to training in epilepsy and diabetes. New policies and procedures are made available to staff and they are asked to read these and The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 20 sign to indicate this has been completed. Not all staff have signed these lists indicating that they have not yet read them. This should be done. The staff files for the last two people appointed were examined to ascertain whether requirements issued at previous inspections had been complied with. The file for a new starter was also available for examination. There appear to be two different reference request forms being used one complies with the National Minimum Standards asking former employers the reason why the person left their employ and the other does not request this information. The registered person must ensure that the correct referee request form is used. A full employment history must also be obtained with dates for each position. There were some missing dates in the employment record for a new starter. These must be obtained. Staff are being employed after a Criminal Records Bureau check has been obtained. At the time of the visit the acting manager requested to start a new employee without this check having obtained a Povafirst check. This was because the staff team is under considerable pressure at the moment covering shifts due to holidays. This is acceptable on this occasion so long as all information has been supplied and two satisfactory references are in place. The acting manager described what would be put in place when starting this person and this meets with the National Minimum Standards. The pre-inspection questionnaire indicated that training has been provided this year in mandatory courses as well as health and safety, COSHH, Protection of Vulnerable Adults and Equal Opportunities. Staff confirmed that training is available to them. The acting manager said that she had not yet received training in supervision skills. This requirement is therefore repeated. A schedule of supervision sessions for all staff was displayed in the kitchen. Staff confirmed that they have monthly staff meetings. Dates for proposed meetings were displayed in the hall. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home will benefit from having a registered manager in place to oversee the management of the home. The quality assurance system involves people living at the home. This system will be further enhanced by a summary of the findings. Systems are in place enabling the home to monitor the health and safety risks promoting the welfare and safety of people living there. Further improvements need to be made to ensure that people living at the home are protected from the risk of fire. EVIDENCE: The deputy manager is presently managing the home. The area manager confirmed that the vacancy for the manager position is being advertised. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 22 Craegmoor have various quality audits that they are issuing over a two-year period to the home for completion. Audits for medication and health and safety were available for inspection as well as an audit for finances that was instigated as a result of a financial discrepancy at the home. The acting manager said that they were expecting to do an infection control audit next. Copies of the Regulation 26 report conducted by managers of other homes were available at the home. Until the home has a registered manager copies of this report must be forwarded to the Commission. The acting manager said that service user satisfaction surveys had not been completed this year. Craegmoor held a Residents Forum Meeting in January 2006 inviting representatives from all their homes to meet together. Part of the agenda included discussing how to make a complaint. Under Regulation 24 a report must be produced based upon this quality assurance system and made available to the Commission. A robust system is in place for the monitoring of health and safety systems in the home. The maintenance person takes responsibility for most of the checks including fire, water temperatures, equipment and window restrictors. The pre-inspection questionnaire confirmed that annual servicing has been completed; certificates were also available for inspection. Fridge and freezer temperatures are not always being recorded. This should be done at least daily. Since the last inspection new fire doors have been fitted although not all doors appear to be adequate, with gaps between the door and the floor. The maintenance person said that this had been reported to the firm who had installed the doors. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 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 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 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 2 3 2 X 2 X 2 X X 2 X The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13 (4) Requirement Timescale for action 30/11/06 2. YA19 13(4)(c) 18(1)(c) The registered person must ensure that risk assessments clearly identify the level of assessed risk and that staff implement the actions to be taken to minimize hazards identified: • travelling in transport • for people with epilepsy when bathing The registered person must 30/11/06 ensure that protocols for a person with diabetes give staff clear guidance about action to be taken if blood levels are outside normal parameters. Staff must have training about Diabetes. The registered person must make arrangements for the safe handling of medication as identified in the text. The registered person must ensure that the required improvements to the environment are completed: Improve the first floor shower facility to make this safe for 3. YA20 13(2) 31/08/06 4. YA24 23 30/11/06 The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 25 more independent use and to ensure this is suitable for the needs of the service users who use it. (Timescale of 31/01/06 and 31/05/06 not met). Carry out repairs to the patio. (Timescale of 31/01/06 and 31/05/06 not met). Remove / cover sharp artex in Room 8. (Timescale of 31/01/06 and 31/05/06 not met). An action plan must be supplied to the Commission by 31/08/06 detailing when these works are scheduled to begin. 5. YA24 23 Ensure that requirements received from the Environmental Health Department regarding the laundry are complied with. (Timescale of 31/05/06 not met) 6. YA30 23(2)(d) The registered person must 31/08/06 ensure that all parts of the home are kept clean and reasonably decorated. The registered person must 30/11/06 ensure that staff have knowledge of the disabilities and specific conditions of service users – such as epilepsy and diabetes. The registered person must 30/11/06 ensure staff are not employed in the home until all necessary and satisfactory information and employment checks have been obtained (see text for detail). (Timescale of 30/11/05 and 31/03/06 not met) Training in communication needs to be provided for all staff. (Timescale of 31/05/06 not met – training arranged for later this year) The registered person must DS0000016601.V301048.R01.S.doc 30/11/06 7. YA32 18(1)(c) 8. YA34 19 9. YA35 18 30/11/06 10. YA36 18 30/11/06 Page 26 The Cedars Version 5.2 11. YA39 26(5)(a) ensure that staff responsible for carrying out staff supervisions receive appropriate training in this. (Timescale of 30/04/06 not met) The registered person must ensure that copies of the Regulation 26 monthly visit are forwarded to the Commission. The registered person must ensure that a report is produced summarising the outcomes of the quality assurance system and a copy made available to the Commission. The registered person must ensure that the fire doors are fit for purpose. 31/03/07 12. YA42 23(4)(iv) 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA7 YA11 Good Practice Recommendations Care plans should be regularly reviewed. Consent should be obtained for the use of monitors in service users’ rooms and a protocol put in place to indicate when and how this is to be used. Staff should receive guidance on how to work in a more enabling and empowering way in order to increase the opportunities for service users to be more independent. A system for recording food provided should be put in place that enables staff to ascertain at first glance whether the diet is satisfactory. A Health Action Plan should be provided for all service users. Bank receipts should be kept with bank statements which should be initialled when audited. Regular statements for savings accounts should be provided by Craegmoor. Sheets kept in the laundry should be stored elsewhere to ensure that they remain dry. DS0000016601.V301048.R01.S.doc Version 5.2 Page 27 4. 5. 6. 7. YA17 YA19 YA23 YA30 The Cedars 8. 9. YA33 YA42 Staff should read policies and procedures as they are reviewed and sign the signature list. Fridge and freezer temperatures should be recorded daily. The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Cedars DS0000016601.V301048.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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