Inspection on 04/07/07 for The Cedars

This inspection was carried out on 4th July 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 14 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 14/08/06

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 Mr Richard Leech Unannounced Inspection 4 , 6 & 9th July 2007 10:00 th th 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.V338067.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.V338067.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) www.craegmoor.co.uk Cotswold Care Services Limited To be Appointed Care Home 9 Category(ies) of Learning disability (9) registration, with number of places The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th August 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 with an outbuilding used for activities and as a sensory area. The home incorporates a day-centre which is used by people living at the Cedars and by some people living elsewhere in the community. The base fee was reported to be £1135 per week, although there is individual negotiation depending on people’s assessed needs. A summary of the Statement of Purpose is displayed in the hall. Prospective service users and others involved in their care are offered information about the home including copies of the Statement of Purpose and Service User Guide. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on a Wednesday morning, lasting until mid afternoon. Further visits took place on the following Friday and Monday during the daytime. During these visits all of the people living in the home were met, along with many of the staff team. The manager was present for the majority of the time. Much feedback was received from other people with an interest in the home including family members and healthcare professionals. Significant findings are included in the report. The manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. During the visits a range of records were checked. These included selected care plans, risk assessments, medication charts, training and staffing files and policies & procedures. What the service does well: Good arrangements are in place to ensure as far as possible that the service can meet the needs of people who move in. People living in the home provided much positive feedback. Some people were asked if they liked living at the Cedars and all replied that they did. They also gave positive feedback about the staff. Staff were seen to be caring and skilled in providing support. People are supported to stay in touch with family and friends. People’s rights are generally respected and they are enabled to take responsibility for aspects of the running of the home, helping them to feel involved in everyday life. A varied and balanced diet is offered which reflects people’s likes and needs. People living in the home feel able to say if they are unhappy about something and that they are listened to. Measures are in place which help to protect the people living in the home from harm and abuse. People have spacious single rooms which are personalised. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 6 There was positive feedback about the way that the home was being run. Systems are in place which help to monitor and improve the quality of the service. Health and safety is well managed. What has improved since the last inspection? What they could do better: Care plans could be made more person-centred to ensure that people’s needs, wishes and goals are more consistently reflected. There is also scope for people to take more control of their lives by further developing the ways that people are supported to communicate and to make choices. Work taking place to update risk assessment and management plans should help to promote the safety of people living in the home when completed. Difficulties with staffing levels have resulted in the people living in the home having limited choices around activities and access to the community. Whilst people’s personal care needs are generally met, a significant failure in basic care resulted in discomfort and health risks for one person living in the home. Some disorganisation and inconsistency in recording of healthcare appointments and outcomes may increase the risk of service users not receiving the healthcare support that they need. Shortfalls were also found in The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 7 the handling of medication. These need to be addressed to make sure that people’s health and wellbeing is safeguarded. Although in general the physical environment is comfortable and homely, some areas need attention so that the Cedars is as comfortable and safe as possible. Staff would benefit from more specialist training about the needs and conditions of the people living in the home. The home has been short staffed, impacting on the quality of care and people’s quality of life. However, there was evidence of steps being taken to recruit new support workers and team leaders, and also a cleaner. Further improvements are needed to recruitment procedures in order to better safeguard for people living in the home. CSCI will consider taking action in respect of requirements which have been repeated. 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. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 8 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.V338067.R01.S.doc Version 5.2 Page 9 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. Good arrangements are in place to ensure as far as possible that the service can meet the needs of people who move in. EVIDENCE: Information was supplied on the AQAA about the admissions procedure. At the time of the inspection the home had one vacancy. The manager said that this would not be filled until the staffing situation had eased (see staffing section). However, a referral had been received and the manager said that the person had visited the Cedars twice. During this time they had met the other people living in the home, joined meals and had spent some time in daycare. Further visits were due to take place. It was suggested that records be kept of each visit. The manager confirmed that the person had been sent copies of the Statement of Purpose and Service Users Guide. It was agreed that the placing authority should be asked for an up to date assessment of needs. The manager had completed her own assessment. One person had moved into the home the previous November. Feedback was received from the person, family members and staff indicating that the admission had been appropriate and well handled and that the person’s needs were being met. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 10 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 & 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. Whilst a care planning framework is in place, forthcoming work on introducing a more person-centred approach should help to ensure that people’s needs, wishes and goals are more consistently reflected. There is scope for people to take more control of their lives by further developing total communication and person-centred care in the home. Work taking place to update risk assessment and management plans should help to promote the safety of people living in the home when completed. EVIDENCE: Care planning files for two people were checked. These included up to date reviews and assessments of need from placing authorities. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 11 The home’s care plans covered areas such as personal care, activities, daily living skills and specific needs relating to people’s conditions. There was reference to principles such as offering choice, involving people in decisionmaking and to rights. The service had a system of monthly reviews, although in some cases these appeared to have ceased in April 2007 or, in one case, January 2007. Whilst in general care plans covered appropriate areas and provided guidance for staff, it was agreed that there was significant scope for improvement. Some care plans were generic, rather then being personalised to the individual. Some plans seen lacked sufficient detail, such as plans about communication which referred only to verbal communication. Another plan about communication included unclear statements such as ‘staff to be able to communicate with me effectively’ without indicating how this could be done. The organisation has a new care-planning framework which is more personcentred. It was reported that this would be introduced by September 2007. It was agreed that a more person-centred approach to care planning should be of great benefit to the people living in the home, helping to ensure that plans reflect their needs, choices, wishes and goals. Some more person-centred work was already in place (‘Essential Lifestyle Planning’) and some work had begun in respect of the new formats. People had care plans referring to the possibility of not being able to consent to medical treatment. These should be reviewed and framed in terms of the Mental Capacity Act 2005. Whilst staff were able to demonstrate reasonable knowledge of people’s needs and conditions there were some areas where understanding could be improved. For example, some detailed care plans were in place around management of diabetes for one person, but staff varied greatly in their knowledge of the content of this guidance (see also section about ‘staffing’). One person living in the home was asked about care plans. They indicated that staff discussed their care plans with them and that they felt involved in the process. Care plans included some reference to restrictions and locked areas of the home, giving the rationale. During the visits to the service people were seen being offered choices, such as about what they ate and how they spent their time. In written and verbal feedback people living in the home indicated that they were offered choices and that they exercised control over their lives. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 12 The manager said that nobody was accessing advocacy at the time. It was agreed that there may be a role for advocacy services for some of the people living in the home. There was discussion with the manager about choices in respect of people with greater communication difficulties. It was agreed that there could be more emphasis on total communication approaches in the home, such as use of pictures and objects of reference. In discussion some staff referred to people making choices through non-verbal communication, although in other cases knowledge about expression of choice through non-verbal means was less developed. See also comments on care plans about communication. Two people’s risk assessments were looked at. One person had risk assessments covering significant areas such as fire safety, scalding, falls and specific activities, providing reasonable guidance and indicating that they were enabled to take risks in a supported way. The second person’s file just had a risk assessment about fire safety. The manager said that work was taking place to fully review the person’s risk assessments. As such, a requirement is not made but progress with this will be checked during future visits. Discussion indicated that one area that would need risk assessment related to challenging behaviour whilst travelling in the vehicle. Examples of assessments of risk and accompanying protocols covering issues such as seizures were seen in other people’s files. The missing person’s file included pre-populated information about people living in the home along with a photograph. However, one had not been completed for the person who moved to the Cedars late in 2006. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 13 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 & 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. Difficulties with staffing levels have resulted in the people living in the home having limited choices around activities and access to the community. Arrangements are made to support the people living in the home to maintain contact with important people in their lives. People’s rights are generally respected and they are supported to take responsibility for aspects of the running of the home, helping them to feel valued and included. People are offered a varied and balanced diet appropriate to their needs, promoting their health and wellbeing. EVIDENCE: The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 14 The home offers a daycare service with dedicated staff. People living in the home were seen taking part in art and craft activities and appeared to be enjoying this. The atmosphere was relaxed and people were seen to receive individual support with art projects. People were also observed playing games with staff, helping to cook and relaxing in the lounge. Daily entries for two people were checked, covering a 15-day period in June and July 2007. Some entries were missing from the sequence. For one person entries were found covering 12 days. The only reference to trips outside of the home was for one visit to their family. Discussion with the manager and staff, along with observation, indicated that there were difficulties engaging the person in daycare activities and that challenging behaviour was sometimes expressed when attempts were made to access the community. However, some staff felt that the person would benefit from more one to one activity time but felt that staffing levels made that difficult to achieve (see also section about staffing). Some added that the person did not like noise/crowds and was rarely seen downstairs besides when it was very quiet. The manager agreed with these sentiments and described some ideas about how this could be addressed. Discussion indicated that the person’s activity levels had picked up in the last week, with several trips out of the home including going swimming. Records provided evidence that the second person was being offered a wide range of activities. During the period sampled these had included contact with family, going for walks, food shopping, having their hair dyed and accessing daycare. There was mixed external feedback about activities. One person commented that ‘the majority of time is spent hanging around the house’ though noted that in the previous couple of weeks there had been an improvement in activity provision. One person referred to people in the home having a ‘limited choice’ of activities, for example, pointing out that trips out were usually in groups rather than one to one and that there were few opportunities for some people to meet others socially. Other comments were made about lack of supervision of the people living in the home at times due to staff shortages. Some of the people living in the home were asked about activities and indicated that they were satisfied with their programmes. However, one person said that they would like to go to church but that there were not enough staff to take them. The manager acknowledged that staffing levels had affected this (see section about staffing). Some staff also commented on short staffing impacting on activities. In the home’s AQAA it was reported that people living in the home had regular 1:1 keyworker days where they chose what to do and where to go. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 15 On the final day of the inspection some people left for a holiday to Wales. Daily records provided evidence of people having regular contact with family and friends, both in person and on the telephone. Surveys from family members indicated that relatives were generally happy with the way that the home promoted contact and kept them informed. Discussion with family members provided further evidence of this. One person commented on how welcome they were made to feel when they visited the home. Specific recording sheets are in place for logging contact with family. However, in many cases these were not being kept up to date. People were seen moving around the home and garden as they pleased, although as noted some risk assessments were in place resulting in certain areas being locked for health and safety reasons. People were offered keys to their bedrooms where assessed as able to manage this and wishing to have one. Reference to people’s preferred form of address was seen in their care planning files. Care plans described promoting independent living skills and involving people in daily life in the home. Throughout the inspection people were seen helping with household tasks in a natural and inclusive way. Daily notes also referred to people helping around the home. A note in the communication book described a rigid timetable of hot drinks for one person. This was discussed with the manager, who said that she had addressed this issue with staff, making it clear that it was not acceptable to impose a limitation in this way without conducting appropriate assessments/consultation and creating a care plan. This may indicate a training need. One staff member said that they had received training which had included discussion about service users’ rights. People were seen eating meals during the visits. The atmosphere was relaxed and people appeared to be enjoying their food. One person was asked about the food they were eating and said that it was nice. As noted, some people were seen helping with cooking and food preparation. During an afternoon tea break on 06/07/07 people were offered fruit. However, one of the oranges was mouldy, suggesting that greater vigilance is needed to ensure that food is disposed of when no longer fit to eat. Some staff felt that the food served in the home could be better and that the budget was too low. The manager felt that this was not the case and that people were offered a good diet including a variety of fresh produce. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 16 Menus provided evidence of reasonable variety and balance being provided in people’s diets, and of people’s special dietary needs being taken into account. A family member commented that, “dietary needs are well met and individual tastes catered for”. There was discussion with the manager about whether people’s choices around food could be improved through the use of total communication approaches. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 17 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 & 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. Whilst people’s personal care needs are generally met, a significant failure in basic care resulted in discomfort and health risks for one person living in the home. Some disorganisation and inconsistency in recording of healthcare appointments and outcomes may increase the risk of service users not receiving the healthcare support that they need. Shortfalls in the handling of medication could compromise the wellbeing of people living in the home. EVIDENCE: Care plans gave information about how people’s personal care needs were to be met. Staff spoken with demonstrated a good understanding of this and of the importance of promoting people’s privacy and dignity. Clear protocols around the response to seizures and to the use of monitoring devices were The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 18 seen and the team was reported to be receiving further external support in this area. As noted, work was taking place on producing more person-centred care plans. This should provide an opportunity to include more reference to any preferences that people may have around personal care, such as in respect of routines or the gender of the person providing support. Examples of weight records were seen. A note was seen in the communication book for late June 07 referring to a service user being badly sunburnt and to the failure to apply cream being neglectful. This was discussed with the manager, who said that there had been a trip to the coast that day but that the staff had not applied sun cream as it had been a cloudy day (although cream had been applied earlier before leaving the home). The manager said that she had investigated this, including speaking with staff and making records on staffing files. Staff had since been reminded of the need to apply sun cream when necessary. CSCI should have been notified of the above incident under Regulation 37. Healthcare records were checked for two people. These were found to have significant omissions, making it difficult to establish if people were being supported to access routine and specialist healthcare services. For example, chiropody appointments were not being consistently recorded on the medical contact summary. These appointments were said to be written up in daily notes, meaning that they would have to be trawled through to check appointments and significant outcomes. Similarly it was not always possible to be certain when people last had a dental check or eye test. Staff reported that one person had last seen a dentist over a year before and had been found to have a rotten tooth. It was reported that nothing could be done until such time as the person presented as being in pain. No reference could be found in available healthcare records to this, nor was an oral healthcare plan found which made note of this important information. It was reported that one person had visited their GP the week before. However, this had not been written up in notes – the most recent entry on the medical contact summary was in 2006. In the last report it was recommended that a Health Action Plan should be provided for all service users. Whilst some work had taken place, further progress was needed for this recommendation to be fully actioned. A requirement about diabetes protocols was found to have been met, although staff knowledge of the content varied (see section about care planning and linked recommendation). Part of the requirement was that staff must have training about diabetes. The manager said that about half of the staff had The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 19 received this training, and that there were plans for remaining staff to access this (see ‘staffing’ section). Letters on people’s files provided evidence of the involvement of the Community Learning Disability Team and other healthcare professionals. Written feedback from healthcare professionals provided a mixed response. Whilst some indicated that they were satisfied with the care provided in the home, others indicated that they were not. Reasons cited included that: • • • • • • Staff did not have sufficient knowledge of the conditions and needs of people living in the home. Inconsistent care practices. Staff not always following guidance and recommendations. Communication difficulties within the team and between the home and involved professionals. Meetings being held in communal areas prone to disturbance. Inappropriate referrals or referrals being termed as urgent without due cause. The service should take the above into account. However, there were positive comments too such as, “all health needs appear to be taken into account and addressed”. Arrangements for handling medication in the home were checked. The organisation has medication policy dated September 2006, accompanied by policy documents covering a wide variety of medication-related issues. A read and sign approach was in operation, although only a minority of staff had signed to say that they had read and understood the policies. Some examples of consent forms signed by people living in the home were seen in respect of the service holding and administering their medication. A copy of the March 2007 BNF (British National Formulary) was available, indicating that staff had access to up to date reference material if necessary. Medication administration records were checked. Some older sheets were stored in an accessible area near the medication cabinet. These and other confidential material (such as letters from the CLDT about people living in the home) need to be stored securely. The following issues were noted with medication administration records: • • Whilst a front sheet noted that one person was allergic to penicillin the actual MAR sheet recorded ‘none known’ in the allergy section. A significant number of gaps were found in administration records for different people, such as for May 8th and 17th 2007 and June 7th, 23rd and 25th. The manager said that she had spoken to staff about this and felt DS0000016601.V338067.R01.S.doc Version 5.2 Page 20 The Cedars • that practice had improved, but acknowledged that further improvement was necessary. One handwritten entry was found with neither a countersignature nor the signature of the author. Records of blood sugar levels for one person were kept in the medication cabinet. A reading of 2.4 was recorded on 07/06/07. The daily record was checked and there was no reference to this very low reading and any action taken as a result. It is strongly recommended that the service’s response/staff interventions be clearly recorded as evidence that the protocol and care plan are being followed. The medication cabinet was checked. Storage appeared to be in order, with the exception of some eardrops opened on 02/06/07 which needed to be discarded four weeks after opening. This timescale had been exceeded and no replacement was available. A list of staff trained to administer medication was seen. Training records provided evidence of people accessing training about the handling of medication. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 21 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 & 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. A satisfactory framework is in place for handling concerns and complaints, helping to make people feel listened to. Measures are in place which help to protect the people living in the home from harm and abuse. EVIDENCE: The service has a complaints procedure available in text and symbol formats. The manager described the approach to complaints, and talked through some current issues related to the vehicles. Complaints about the vehicles being unsuitable had been made, triggered in part by an incident of challenging behaviour. During the inspection the manager and staff expressed the view that larger vehicles should be provided since the current people-carriers resulted in service users sitting too close, in turn resulting in some incidents of challenging behaviour and harm. This should be taken forward. Some of the people living in the home were asked whether they felt confident telling the manager or staff if they were unhappy about something. They replied that they did and indicated that staff were good listeners. Family members expressed general confidence about raising issues too. One person commented, “the manager/deputy have always followed up any concerns and attempted to resolve them…”. However, some feedback was received from a The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 22 person who felt that the home was not always very receptive to concerns and complaints. The service has a policy about the protection of vulnerable adults dated December 2006. Only three staff had signed at the time (see recommendation made in previous section about the read and sign approach). A copy of the whistle blowing policy was displayed on a notice board and staff spoken with confirmed their knowledge of this procedure. A person who has moved on from the home still has a small cash balance held there. The manager said that they were working towards getting the money to the person. Some examples of inventories were seen. One had last been updated in January 2007. They should be kept as up to date as possible. Some records of finances for the people living in the home were seen, along with receipts. Those viewed appeared to be in order. Staff spoken with confirmed their understanding of their adult protection responsibilities. Some staff had accessed external training about this. The manager stated that the organisation now had a workbook on the subject, but expressed a preference for continuing to access external training. It was pointed out that the local authority was continuing to offer a free half-day ‘Alerter’s Guide’ course at various venues throughout the county. Staff reported that there was no restrictive physical intervention in the home. They talked through how they responded to challenging behaviour, demonstrating knowledge of appropriate techniques and approaches. Some staff were seen supporting people who were anxious and upset, handling the situations calmly and professionally. In the AQAA it was reported that staff may have a repeat CRB check every 3 years as part of safeguarding the people living in the home. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 23 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 & 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. In general an appropriate environment is provided for the people using the service. However, some shortfalls could compromise people’s safety and comfort. EVIDENCE: All communal areas were checked apart from the wooden outbuilding. Some people also showed their bedrooms. Communal areas were seen to be reasonably decorated and homely. The hallway carpet was badly stained and needs to be replaced. It was reported that this was going to be done. The lounge carpet was also stained and had some untidy joins which could be trip hazards. The sofas in the lounge had rips and some staff reported that they were odorous at times. These should be replaced. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 24 The manager agreed that many areas of the home were tired or had stained/worn paintwork and would benefit from redecoration. The area manager was present at one point of the inspection, and said that some redecoration of the home was being planned. There was also feedback from family members who felt that the home would benefit from redecoration of many of the communal areas in a rolling programme. It was acknowledged that there is a high level of general wear and tear in the home. In the AQAA it was reported that a decoration plan was to be implemented. It was also pointed out that in the last 12 months new dining room chairs had been purchased and that the dining room and daycare areas had been repainted. The manager was planning to relocate the office from the second floor to a room downstairs, since the existing room was proving to be too remote and lacking in space. In the last report a requirement was made to improve the first floor shower facility to make this safe for more independent use, and to ensure this was suitable for service users’ needs. The manager said that there had been discussions with the Community Learning Disability Team about converting it into a wet room, though questions had been raised about whether the space would be suitable for this. Whilst it is accepted that consideration has been given to how this requirement could be met, it is repeated. The manager said that she would still favour a wet room being provided. The room was also seen to be in need of redecoration as there were patches of mould. One person liked to prop open their bedroom door. This was being done with an object. It was agreed that, for this to be done safely, a self-closing device linked to the fire alarms would need to be fitted. Some hazardous artex in bedrooms had been smoothed over. One bedroom on the second floor (vacant at the time) had a rotten windowsill. Appropriate work needs to be undertaken to resolve this. Consideration should be given to checking the state of all of the windows and replacing other sills and frames as necessary. Consideration could also be given to replacing the windows with double-glazed units. People living in the home expressed satisfaction with their bedrooms. Their rooms were seen to be personalised and individually decorated. The garden was reasonably maintained and was seen to be well used by the people living in the home. Some rabbits were being kept outside. There was garden furniture and a trampoline available for use. Work had been done to improve the patio, as required in the last report. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 25 A new laundry facility was in operation on the ground floor. This had been the subject of a requirement in previous reports. A cleaning schedule was seen in the kitchen. A spillages and first aid kit were also seen. The home was seen to be generally clean, although a number of areas had cobwebs. Staff reported some difficulties with keeping the property clean whilst providing care and some reference was seen in the communication book to this. The manager reported that the home had been without a cleaner for a while, but that one was due to start shortly. This should help to reduce the pressure on care staff and promote cleanliness and hygiene in the home. Some feedback was given by family members, stating that whilst the home was clean it needed redecoration to make it brighter and fresher. Another person stated that the home ‘maintains good standards of cleanliness’. However, comments were made about unsatisfactory standards of cleanliness in some of the toilets at times. A sanitary bin in a downstairs bathroom was missing its lid. This needs to be addressed. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 26 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 & 35 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. Staff are caring and competent, and have opportunities for professional development, promoting the quality and consistency of care. Additional specialist training would enhance their skills and knowledge helping to further improve standards of care in the home. The ability of the team to meet people’s needs has been compromised at times by short staffing. Further improvements are needed to recruitment procedures in order to better safeguard people living in the home. EVIDENCE: It was reported that 40 of the staff team were qualified to NVQ level 2 or above in health and social care. One person was due to complete the qualification shortly after the inspection. The deputy manager was also undertaking the Registered Manager’s Award. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 27 Staff were observed to interact with service users in a caring, skilled and responsive manner. The people living in the home appeared comfortable with the staff. They gave positive feedback about the team. Comments included that staff were ‘nice’ and ‘good’. They indicated that staff were good listeners. Information was seen in the home about many of the conditions experienced by the people living there. See section about training for comments on staff knowledge of these. The manager and staff were open about the home having experienced a period of short staffing. There was documentary evidence that new staff were being recruited. The manager also described plans to have a pool of bank staff to access when necessary. The manager and staff felt that a minimum of three carers were needed to meet people’s care and activity needs and to keep them safe (with the manager, deputy and daycare staff being supernumerary). Many staff felt that a minimum of four people per shift was preferable. The rota indicated that there had recently been shifts when levels had fallen to two staff (e.g. May 19/20 and 26/27). As noted earlier some people had expressed a wish to attend church but this had not been possible. One person living in the home volunteered the view that there were not enough staff at times. This was also expressed by family members who provided feedback about the home. The manager said that she was having to cover many of the care shifts, taking her away from management duties. Recruitment and selection was considered. The manager described the steps taken when recruiting new staff. A provisional staffing file for somebody not yet working in the home was checked. There were some gaps in employment history. The manager was advised to explore and document these as part of the recruitment process. Two staff files were checked for people who had been recruited. These appeared to be satisfactory besides a gap in employment of about one year not being accounted for. In addition, one person had given a friend as a referee. It was agreed that two professional references should be sought in all cases as far as possible. Training records were checked. These provided evidence that the staff team were accessing a variety of mandatory and specialist training relevant to their roles and responsibilities. This included training about epilepsy, equality & diversity, adult protection and the management of challenging behaviour. In the last report a requirement was made to ensure that staff had knowledge of the disabilities and specific conditions of service users, such as epilepsy and The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 28 diabetes. Whilst some staff had received appropriate input about some of the significant conditions experienced by people living in the home other staff had not received such training. Discussion indicated that this input would be beneficial in terms of improving some people’s knowledge and understanding of service users’ needs and conditions and how these might change in the future. External feedback was also obtained from professional and family members which suggested that staff needed to improve their knowledge and understanding of particular conditions. The manager agreed, saying that she was planning to arrange training for the people who had been unable to attend previous input of this kind, as well as for newer staff. The manager said that some training about epilepsy had been provided in June 2007, and that another session was being arranged. Records indicated that some staff had received training in areas such as handling of medication, management of challenging behaviour several years ago. Consideration should be given as to whether people would benefit from refresher training in areas where they have not had input for some time. The manager felt that staff needed more input around the management of challenging behaviour, including how to safely intervene physically as a last resort in exceptional circumstances. At the time of the inspection a specialist had begun working with the team around the assessment and management of challenging behaviour. It was reported that they would be providing training for the team specific to individual service users, and would be assisting with the writing of care plans. Records indicated that some people had last received training about fire safety as far back as May 2005. The manager said that the organisation provided an internal training pack about fire safety for staff to work through, but expressed reservations about whether this met their training needs in this area. The fire risk assessment was checked but the section about training needs had not been fully completed. It was agreed that this was the starting point in terms of identifying what training staff needed and at what frequency. Advice could be sought from the local fire authority if necessary. Some training had been provided for people about signing. The manager said that further training was planned for newer staff. Some staff had not heard of the Mental Capacity Act 2005. Training/input should be provided to equip with necessary knowledge about this important piece of legislation. The manager said that she had received some input about this. The manager reported that some of the staff had been trained in the use of a rescue medication but that many staff, particularly people who had recently joined the team, had not. As a result the protocol was to call 999 in particular The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 29 circumstances. The manager said that she was aiming to arrange further training in order that all staff felt confident administering the medication when required. The manager described plans to create a written rather than verbal handover. This should be done, particularly as some staff reported that handovers did not happen on occasions. Some staff reported that staff meetings were infrequent. These should be regular – at least every two months. The manager reported that the deputy manager had received training about conducting supervision meetings, as per a requirement in the last report. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 30 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 & 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. Some management issues have impacted on the running of the home, resulting in underperformance in some areas. Systems are in place which help to monitor and improve the quality of the service, although there is scope for further development in this area. Health and safety is well managed, promoting the wellbeing of people living and working in the home. EVIDENCE: The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 31 At the time of the inspection the acting manager was awaiting return of her Criminal Record Bureau certificate. Upon receipt of this she intended to apply to CSCI for registration. The acting manager reported that she had obtained the NVQ level 4 in health and social care as well as the Registered Manager’s Award. Staff were generally positive about how the home was running. It was clear that there had been some confusion about management arrangements for a period earlier in the year when both the manager and deputy were away. Any future arrangements for cover in such circumstances will need to be more clear and robust. At the time of the inspection the deputy manager had been on extended leave. The manager said that she was expected to return in the near future. Team leaders were being recruited and it was agreed that this should help to ease the staffing situation and take some pressure off the manager by creating a stronger management structure. Some staff commented on how necessary it was to have team leaders back in post. Positive feedback about how the home was being run was obtained from family members. For example, some commented that they had ‘much faith’ in the manager. See other sections of the report for key areas identified as requiring improvement and therefore management attention. Quality assurance was considered. Regulation 26 reports are being regularly forwarded. The organisation has a series of different audits, some conducted internally and others by visiting teams. Examples of these were seen, including outcomes and actions arising. An audit by the supplying pharmacy was also seen from March 2007. An agenda and minutes for a service users’ meeting on 14/05/07 was seen. This had included asking people questions about the home and the care they received. Whilst the information obtained was very useful no evidence was seen of any kind of follow up/actions arising. Work on total communication, described earlier, should help to give some people with communication difficulties more of a voice. The manager said that informal feedback was regularly obtained from people with an interest in the home. There were plans to distribute surveys to give people another way of providing feedback about the service. This would be a positive development, as family members completing surveys for CSCI provided a huge amount of feedback about the home which would be helpful for the service to gather directly. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 32 The manager said that as part of quality assurance she had been seeking external feedback from professionals involved with the home. Feedback had included concern about staff knowledge of some of the conditions experienced by service users (see earlier comments). The manager’s strategy to address this included recruiting team leaders to promote consistency, improving care planning and staff knowledge of care plans and providing further specialist training. Health and safety arrangements in the home were considered. Some environmental risk assessments from April and June 2007 were seen, covering various hazards around the home. Fridge and freezer temperature records were seen in the kitchen. Other routine records were seen including testing of hot water temperatures and portable and gas appliances. The fire log appeared to be satisfactory. As noted, further work should be done on the fire risk assessment, as a starting point to establishing the type and frequency of fire training to be provided for staff. The manager confirmed that some work had been undertaken on fire doors as required in the last report. An asbestos survey had been carried out in August 2006. Some asbestos had been identified, although it was not clear whether it was recommended that this should be left undisturbed or removed. Clarification should be sought from the company which conducted the survey and their recommendations followed through. An external consultancy had recently conducted a health and safety audit and made some recommendations. This included identifying a trip hazard in an outbuilding. It was agreed that this would be risk assessed. The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 33 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 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 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 2 2 1 x 2 x 2 x x 3 x The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 34 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 YA12 Regulation 12 (4) b. 16 (2) m &n Requirement Provide an appropriate programme of activities in consultation with service users. This must include supporting people to go to a place of worship if they wish to. Ensure that people living in the home are protected from over exposure to the sun, including through application of sun cream when necessary. Ensure that CSCI is notified of incidents as described in Regulation 37. Staff must have training about diabetes. Timescale of 30/11/06 partly met. Ensure that medication is discarded as necessary, as per accompanying instructions, and that replacements are ordered/available in time if required. Ensure that medication administration records form a complete and accurate record of the administration of medication in the home. Confidential material about DS0000016601.V338067.R01.S.doc Timescale for action 31/10/07 2 YA18 12 (1) 06/08/07 3 4 5 YA18 YA19 YA20 37 18(1)(c) 13 (2) 06/08/07 31/10/07 06/08/07 6 YA20 17 (1) b 06/08/07 Page 35 The Cedars Version 5.2 7 YA24 23 (2) d medication and healthcare must be stored securely. Clean or replace the hallway carpet. Clean or replace the lounge carpet and attend to joins such that they do not pose a trip hazard. Fire doors must not be propped open. If they are to be kept open then a self-closing device linked to the fire alarms needs to be fitted. Appropriate work needs to be undertaken on the rotten and split second floor window frame/sill. Improve the first floor shower facility to make this safe for more independent use and to ensure this is suitable for the needs of the service users who use it. (Timescales of 31/01/06, 31/05/06 and 30/11/06 not met). Ensure that all sanitary bins have lids. There must be sufficient numbers of staff on shift to meet the needs of the people living in the home at all times. Ensure staff are not employed in the home until all necessary and satisfactory information and employment checks have been obtained (timescales of 30/11/05 and 31/03/06 not met. Timescale of 30/11/06 also not met in respect of employment history). Ensure that staff have appropriate knowledge of the disabilities and specific conditions of service users, such as epilepsy, diabetes, downs syndrome and autism (timescale of 30/11/06 partly met). DS0000016601.V338067.R01.S.doc 31/10/07 8 YA24 13 (4) 23 (4A) 31/10/07 9 YA24 23 (2) b 31/10/07 10 YA24 23 (2) a & d 30/11/07 11 12 YA30 YA33 16 (2) j 18 (1) a 31/08/07 06/08/07 13 YA34 19 06/08/07 14 YA35 18 (1) c 31/10/07 The Cedars Version 5.2 Page 36 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 YA2 YA6 Good Practice Recommendations Keep records of visits made to the home by prospective service users. Aim to review care plans monthly as per the home’s policy. Move ahead with introducing the new person-centred planning formats. Improve the detail/scope of certain plans, for example about communication (see text). Reframe care plans about consent to medical treatment in terms of the Mental Capacity Act 2005. Ensure that staff have a good knowledge of care plans. Consider whether some of the people living in the home may benefit from accessing advocacy services. Consult with service users about whether they wish to access advocacy. Consider the scope for developing total communication approaches in the home, particularly for people who have greater difficulty communicating verbally. Create a missing person’s information sheet with a photograph for the person who moved to the home in November 2006. Ensure that daily record sheets are consistently stored in one location so that they form a sequence. Given that there is a specific format for logging contact with family, these should be consistently completed. Exercise greater vigilance when offering service users fruit to ensure that it is fit to eat. Consider whether people’s choices about food could be improved through the use of total communication approaches, as discussed. Aim for the new person-centred care plans to include more information about how people wish to be supported with their personal care needs. DS0000016601.V338067.R01.S.doc Version 5.2 Page 37 3 4 YA6 YA7 5 6 7 8 9 10 11 YA7 YA9 YA12 YA15 YA17 YA17 YA18 The Cedars 12 YA19 A Health Action Plan should be provided for all service users. Ensure that there is a clear and easily accessible record and summary of all healthcare appointments and outcomes. When there are significant outcomes which have implications for care and support provided in the home ensure that these are clearly reflected in care plans without delay. Take into account feedback received from healthcare professionals about ways that the service could improve. Implement the read and sign approach concerning the medication policy (and other policies to which this relates). It is strongly recommended that the service’s response/staff interventions in respect of blood sugar readings which are high or low (as defined in protocols) be clearly recorded, as evidence that the protocols and care plan are being followed. Handwritten entries on MAR sheets should be signed by the author and countersigned by a person who checks the entry for accuracy. Ensure that allergy information on MAR sheets is accurate/corresponds to information elsewhere on people’s files (see example in text about penicillin). Larger vehicles should be provided, in view of the issues around service users’ safety and comfort identified with the current vehicles. Keep inventories of belongings as up to date as possible. The internal training pack about adult protection should be seen as complementing rather than replacing external training on the subject. Redecorate communal areas of the home which are ‘tired’, or where there is stained or worn paintwork. Consult with the people living in the home about how they would like the home to be decorated. Consider replacing the sofas and chairs in the lounge. Consideration could be given to checking the state of all of the windows and replacing any sills and frames found to be in an unsatisfactory state. Consideration could also be given to replacing the windows 13 YA20 14 15 YA22 YA23 16 YA24 17 YA24 The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 38 18 19 20 21 YA32 YA33 YA34 YA35 with double-glazed units. Take forward plans for shift handover to be documented rather than just being verbal. Aim for staff meetings to be regular (at least every two months). References should always be professional rather than personal as far as possible. Consideration should be given as to whether people would benefit from refresher training in areas where they have not had input for some time (see examples in text). Consider whether staff require further training about the management of challenging behaviour, including about how to safely intervene physically as a last resort in exceptional circumstances in accordance with Department of Health guidance. Training/input should be provided to equip staff with necessary knowledge about the Mental Capacity Act 2005. It is strongly recommended that the training needs section of the fire risk assessment be fully completed, to formally identify what fire safety training staff need and at what frequency. Advice could be sought from the local fire authority if necessary. Ensure that the follow up/actions arising to service users’ meetings are logged and that there is an audit trail of who carried each action forward (or tried to), when and with what result. Take forward plans to formally survey people with an interest in the home as part of the quality assurance strategy. Clarification should be sought from the company which conducted the asbestos survey in 2006 about their recommendations and these should be followed through. 22 YA35 23 YA39 24 YA42 The Cedars DS0000016601.V338067.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 - 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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