Inspection on 28/06/07 for The Cedars Christian Residential Home

This inspection was carried out on 28th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Cedars Christian Residential... 26/01/06

The Cedars Christian Residential... 22/10/05

The Cedars Christian Residential... 16/03/05

The Cedars Christian Residential... 08/09/04

The Cedars Christian Residential... 09/03/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Cedars Christian Residential Home The Cedars 22 Redlake Road Pedmore Stourbridge West Midlands DY9 0SA Lead Inspector Lesley Webb Key Unannounced Inspection 28th June 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000025045.V341581.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000025045.V341581.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars Christian Residential Home Address The Cedars 22 Redlake Road Pedmore Stourbridge West Midlands DY9 0SA 01562 882299 F/P01562 882299 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) Mrs Jenkins Mrs Jenkins Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (22), Physical disability (2) DS0000025045.V341581.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 22 OP, 2 PD and up to 1 MD Date of last inspection 26th January 2006 Brief Description of the Service: The Cedars is a large Victorian property built in 1902 and registered as a care home in 1984 by the current registered provider. The property is located in a residential area of Pedmore close to the town of Stourbridge. It has easy access to a main bus route, shops and other amenities. The home is registered to care for a maximum of 22 people, 19 of whom fall within the category of old age, 2 physical disability and 1 dementia. There are 20 single bedrooms and one double bedroom. 15 of these rooms have en-suite facilities and two have a shower. Residents’ accommodation is provided on three floors all of which can be accessed by a passenger lift. There are bathrooms with assisted baths on the ground and first floors. The home has three lounges and a dining room, all of which are tastefully decorated and furnished to a high standard. There is generous garden space to the front and rear, which appeared well maintained for the time of year. Car parking is available at the front of the home. DS0000025045.V341581.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this visit over a day, from 9.15am to 6.15pm with the home being given no prior notice. During the visit time was spent talking to people who live at the home, examining records and observing care practices before giving feedback about the inspection to the registered manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking three individuals care provided at the home. For example the people chosen were male and female, from different backgrounds and have differing support needs. Fees charged for people currently living at the home range from £370.00 per week to £445.00. Fees cover accommodation, linen, towels, lighting, heating, laundry, personal care and meals. Not included are hairdressing, newspapers, telephone, aromatherapy and private medical treatment. The inspector was shown full assistance during the visit and would like to thank everyone for making her welcome. What the service does well: Assessments processes are good ensuring people can be confident that the home can meet their needs. For example all residents files that were sampled contained assessments that cover all areas as detailed in the National Minimum Standards for Older Persons, a copy of the terms and conditions of residency and evidence of visits to the home. The home should be commended for involving residents and their representatives in the compilation and reviewing of plans with all of those sampled containing evidence that this is a regular occurrence through both formal reviews and regular key worker meetings. Management of residents’ health care is excellent within this home. As one resident explained, “They send for doctor if needed, chiropodist, opticians all come to the home, sort batteries for hearing aids, they give me a stock so I never run out”. The principles of respect, dignity and privacy are put into practice. For example on arrival at the home the inspector found that the majority of residents were still in bed despite it being after 9am. A member of staff explained that there were no set times for rising as it was found that by doing this residents could tend to their own personal needs without assistance due to DS0000025045.V341581.R01.S.doc Version 5.2 Page 6 not having to rush to the dining room for breakfast. This was confirmed by a resident who stated, “I try to do as much as possible for myself, but have a buzzer in my room that I use if need help, staff bring you breakfast in bed on a tray if you wish or you can go to the dining room”. Residents living at this home are supported to participate in activities as per their needs and wishes. Activities include exercise classes, outings, quizzes and craft classes. During the inspection time was spent sitting and talking with residents in the lounge and speaking with individuals in their rooms. Residents told the inspector that their families and friends are able to visit any time. Residents are encouraged to be involved with choices relating to the décor of their rooms, are encouraged to bring personal items on admission, can choose when and where to eat and residents meetings occur in order that their views and opinions are not only sought but acted upon. During the inspection residents agreed that the inspector could join them at lunchtime to partake in a meal. The ladies at the table where the inspector sat all complimented the food confirming that it is always of a good quality and well presented. The atmosphere was very relaxed, with quiet music in the background. The dining room looks onto the garden area and is tastefully decorated with matching tablecloths, serviettes, napkin rings and matching cutlery. The home should be commended for the efforts taken to ensure residents are supported to raise issues and concerns. Residents are encouraged to raise issues in the regular residents meetings and are discussed and recorded in care planning. Whilst talking to residents one explained, “Another thing that is good about this place they have residents meetings where we are told to speak our mind, so I told them I want more chips, they do their best to sort problems”. The home makes every effort to ensure residents live in an environment that is furnished and decorated to a very high standard. Many residents that were spoken to complimented the cleanliness of the home. For example one person stated, “The home is always clean, it was the thing I liked when first visited, never any smells”. Residents praised the staff at the home, examples of this include, “The staff are lovely, I only have to press button and they come as soon as they can” and “The girls come and sit and chat every day, give me time, listen, they are lovely, ask if I’m alright, notice if your quiet”. Many of the staff working at the home have do so for many years, with some between ten and fifteen years, ensuring consistency in support to residents. Systems for the management of resident’s monies are good. The Home has a facility for the safe keeping of any monies and valuables and there is access to DS0000025045.V341581.R01.S.doc Version 5.2 Page 7 a safe if necessary. The records and finances of three residents were sampled and all found to be accurate. What has improved since the last inspection? What they could do better: Further improvements to some medication practices will offer further safeguards to residents. These must include taking action to improve the recording of medication to ensure residents are not placed at risk. Improvements must be made is in submission of notifications in line with Regulation 37 of the Care Home Regulations 2001 to ensure residents are protected by the homes recording systems. The home must seek advice from a suitably qualified person regarding the gap between the bedrail and mattress for a named resident and implement any recommendations made in order to reduce the risk of injury. Until such time as this has been obtained the home must complete a detailed risk assessment and complete regular checks on equipment in use in order to reduce the risk of injury. DS0000025045.V341581.R01.S.doc Version 5.2 Page 8 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. DS0000025045.V341581.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000025045.V341581.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective people considering this service and their representatives have the information needed to decide on its suitability. They have their needs assessed and contract that clearly tells them about the service they will receive. EVIDENCE: Information supplied by the home prior to the inspection states ‘prior to admission taking place; an in-depth thorough assessment is completed. This is usually within the service users home. If the assessment is appropriate, it is suggested that the potential service user has a day’s trial within the home. Although rehabilitation is not really a service that is provided within the home we do on occasions provide respite care. That is if a vacancy is available on request of respite. Respite care undergoes the same initial assessment as is DS0000025045.V341581.R01.S.doc Version 5.2 Page 11 outlined a ‘needs led’ package of care is set up to ensure the service user maintains their independence whilst at the home’. The home also supplied information stating that to improve admissions processes further they have ‘assigned one person to take charge of assessment/admissions, to ensure consistency and help to ease the situation of any resident coming into the home’. Through examination of records, discussions with management and residents the inspector found these statements to be an accurate reflection on systems and services within the home. For example all residents files that were sampled contained assessments that cover all areas as detailed in the National Minimum Standards for Older Persons, a copy of the terms and conditions of residency and evidence of visits to the home in order to decide on its suitability. All residents that the inspector spoke to confirmed that the home meets their needs. As one person explained, “I came to stay here first for respite, it was recommended to me. I was very down when I first came here, the thought of giving my home up was heartbreaking, but after a while they gave me one of the bigger rooms with an en-suite and now I am quiet content”. The home does not offer intermediate care. DS0000025045.V341581.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home are involved in decisions about their lives and play an active role in planning the care and support they receive. The health and personal care the residents receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Further improvements to some medication practices will offer further safeguards to residents. EVIDENCE: As at previous inspections care planning is good within the home ensuring residents’ needs are appropriately managed. There is a standardised format in place that identifies health, social, physical care and psychological needs. The home should be commended for involving residents and their representatives in the compilation and reviewing of plans with all of those sampled containing evidence that this is a regular occurrence through both formal reviews and DS0000025045.V341581.R01.S.doc Version 5.2 Page 13 regular key worker meetings. It is recommended that where possible residents sign the minutes of the key worker meetings to further evidence their involvement and participation in this process. It is also recommended that a format be introduced that allows for detailed recording of care needs if a resident develops areas where additional support is required outside of their normal needs, for example when returning to the home from a hospital admission where additional support may be required. This would promote further the holistic approaches to care management already in place. The management of residents’ health care is excellent within this home. Records and discussions with residents confirm that people have access to health care professionals such as opticians, chiropodists, general practitioners and district nurses. For example one resident explained, “They send for doctor if needed, chiropodist, opticians all come to the home, sort batteries for hearing aids, they give me a stock so I never run out”. Assessments are completed for residents at risk of falling, moving and handling, pressure sores and for tissue viability. On all files sampled assessments had been reviewed on a regular basis. It was also pleasing to find that all residents’ choices relating to personal care and assistance are recorded in their care plans. The medication systems were examined. The home has recently changed the system for storing and recording medication, now using a monitored dosage system. Policies and procedures including those for self-medicating, controlled drugs, storage, administration, training, disposal, homely remedies and covert administration are in place. All are detailed and give clear instructions that comply with relevant legislation. A number of medication errors were found including dates of administration not corresponding with dates of administration, dates of medication entering the home missing and some medication stock being higher than what should be in place (indicating medication has been signed for to say given but not administered). The inspector acknowledges it is a new system that has been introduced to the home but instructed action must be taken to improve the recording of medication to ensure residents are not placed at risk. The registered manager and general manager for the home stated that an emergency staff meeting would be held the next day and action taken immediately to rectify the situation. The storage for ‘fridge line’ medication and controlled drugs is appropriate. It is recommended that the date that eye drops and prescribed creams need to be discarded be recorded on the medication administration records as an additional safeguard to residents. It is also recommended that the home reviews the amount of medication stored as ‘stock’ as some was found to be excessive and above what would be needed for a 28 day cycle (this being the maximum timescale before prescriptions are ordered) and that the home obtain syringes in order that accurate measurements of liquid medication can be obtained. Again improvements in these areas would offer greater safeguards to residents. Finally it is recommended that the home obtain the Commission for Social Care guidance ‘Administration of Medication DS0000025045.V341581.R01.S.doc Version 5.2 Page 14 in Care Homes’ from its website to ensure the practices and systems within the home meet current good practices guidelines. Also as at previous inspections an abundance of evidence was found that indicates the principles of dignity and privacy are promoted within the home. For example on arrival at the home the inspector found that the majority of residents were still in bed despite it being after 9am. A member of staff explained that there were no set times for rising as it was found that by doing this residents could tend to their own personal needs without assistance due to not having to rush to the dining room for breakfast. The flexible routines within the home were also confirmed by many of the residents that the inspector spoke to. As one person explained, “I try to do as much as possible for myself, but have a buzzer in my room that I use if need help, staff bring you breakfast in bed on a tray if you wish or you can go to the dining room” and another “The staff are lovely, I only have to press button and they come as soon as they can. I do a lot for myself, I’m very able, and the only thing they help me with is when I have a bath”. Throughout the visit the inspector witnessed staff knocking on bedroom doors before entering and talking to residents in a friendly yet respectful manor. The home recognises the importance of promoting residents’ privacy and dignity, and strives to continue to make improvements in this area. For example since the last inspection a second dining room has been implemented for those residents who may require a little help with feeding, this ensures their dignity and privacy has been maintained. DS0000025045.V341581.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about their life style. Social and recreational activities meet individual’s expectations. Residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: Residents living at this home are supported to participate in activities as per their needs and wishes. As one resident explained, “They do exercise classes and sometimes have outings, there is no driver at the moment so the manager takes us in her car. Four of us went out in two cars recently. They do craft classes, once a week a cross word and quiz, I have won three times. They bring an activity programme round each week; I love my knitting and love reading”. Information supplied by the home prior to the inspection states ‘Service users are encouraged to have visitors through out the day. We do ask that visitors DS0000025045.V341581.R01.S.doc Version 5.2 Page 16 don’t come during meal times, unless they would like to eat with their friend/relative. Visitors have a choice where to see service users and this can be mutually agreed’. This information was found to accurately reflect practices within the home. During the inspection time was spent sitting and talking with residents in the lounge and speaking with individuals in their rooms. Residents told the inspector that their families and friends are able to visit any time. Residents are helped to exercise choice and control over their lives. As mentioned in other parts of this reports where possible structures are flexible in order to support residents to have control over decisions relating to their care. For example residents are encouraged to be involved with choices relating to the décor of their rooms, are encouraged to bring personal items on admission, can choose when and where to eat and residents meetings occur in order that their views and opinions are not only sought but acted upon. Details of advocacy agencies are displayed in the foyer. During the inspection residents agreed that the inspector could join them at lunchtime to partake in a meal. A menu was displayed on each table however several residents pointed out that what was detailed on the menu for that day was different to the meals offered by staff. It is recommended that greater care be taken to ensure the menu on display accurately reflects choices on offer in order that residents can make informed choices. The meal was very tasty and very well presented. The ladies at the table where the inspector sat all complimented the food confirming that it is always of a good quality and well presented. Staff offered a variety of drinks during the meal. The atmosphere was very relaxed, with quiet music in the background. The dining room looks onto the garden area and is tastefully decorated with matching tablecloths, serviettes, napkin rings and matching cutlery. DS0000025045.V341581.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse and have their rights protected. EVIDENCE: The home should be commended for the efforts taken to ensure residents are supported to raise issues and concerns. The complaints procedure is in the service user guide as well as in the statement of purpose. The policy is also on display on the residents /visitors notice board. Residents are encouraged to raise issues in the regular residents meetings and are discussed and recorded in care planning. Whilst talking to residents one explained, “Another thing that is good about this place they have residents meetings where we are told to speak our mind, so I told them I want more chips, they do their best to sort problems”. Information supplied by the home prior to the inspection states that there have been six complaints since the last inspection. Records of these were examined during the inspection with further evidence obtained from these that demonstrates the home not only listens to peoples concerns but also takes action to resolve. For example one person was not happy with the window in their bedroom resulting in this being replaced and another that they DS0000025045.V341581.R01.S.doc Version 5.2 Page 18 were not happy with the seating arrangements in the dining room resulting in alterations being made. The home has an adult protection procedure which comply with The Public Disclosure Act 1998 and a copy of the Department of Health’s guidance ‘No Secrets’ is also available. The homes procedure appears very detailed and informative. Information regarding a local advocacy service is on display at the entrance to the home in order that residents and their relatives have access to additional support if needed. Seventeen of the twenty-five staff employed at the home have received training in adult abuse ensuring they have knowledge and can ensure residents are protected. DS0000025045.V341581.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment. EVIDENCE: The home makes every effort to ensure residents live in an environment that is furnished and decorated to a very high standard. Information supplied by the general manager prior to the inspection states ‘we are constantly striving to improve the home and its surroundings for residents, for example bedrooms are refurbished whenever a new resident is moving into the home and they are consulted on colour schemes’. This was confirmed by one resident who explained, “My room is lovely, lovely view, I was asked what colour I wanted it DS0000025045.V341581.R01.S.doc Version 5.2 Page 20 painted”. A tour of the building revealed pleasant and well-maintained rooms and furniture of a very high quality. The proprietor and manager of the home should be congratulated for the effort and resources put in place to ensure the home is continually improved. Since the last inspection new windows have been fitted in the laundry, new patio doors within the extension and three bedrooms refurbished. Planned improvements in the next twelve months include fitting a new kitchen and refurbishing bathrooms. Infection control standards appear good within the home, with all areas that were seen being clean and free from unpleasant odours. On the day of inspection the laundry room was in the process of being refurbished, with all facilities appearing to meet infection control guidelines. Many residents that were spoken to complimented the cleanliness of the home. For example one person stated, “The home is always clean, it was the thing I liked when first visited, never any smells”. All staff have either received infection control training or have been booked on a course to complete this. DS0000025045.V341581.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the staff in the home are trained, skilled and in sufficient numbers to support residents who live there. EVIDENCE: The numbers and skill mix of staff working at the home appears appropriate to meet the needs of residents. Information supplied by the home prior to the inspection states that ‘each morning shift consists of one senior and three carers, a manager, secretary, cook and handyman. Afternoon shifts there is one senior and two carers and two carers of a night’. There are twenty-five staff, thirteen that hold a national vocational qualification, with two others due to commence this shortly. Residents praised the staff at the home, examples of this include, “The staff are lovely, I only have to press button and they come as soon as they can” and “The girls come and sit and chat every day, give me time, listen, they are lovely, ask if I’m alright, notice if your quiet”. Many of the staff working at the home have do so for many years, with some between ten and fifteen years, ensuring consistency in support to residents. Recruitment practices are good within the home ensuring residents are protected from harm. All staff files that were sampled contained all records DS0000025045.V341581.R01.S.doc Version 5.2 Page 22 required by regulation including Criminal Record Bureau disclosures, references and application forms. For staff that undertake additional shifts written agreements were on file that comply with the Working Time Regulations. It is recommended that risk assessments be completed for staff that regular undertake additional shifts to ensure the manager is satisfied they are fit to care for residents and do not pose a risk. As mentioned above staff appear to have the right skills to care for residents, with some having received training in diabetes and dementia. It is recommended that further work be undertaken to access specialist training for falls management, tissue viability and continence management in order that staff gain greater knowledge in these areas and to meet the needs of residents. DS0000025045.V341581.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, and there are effective quality assurance systems developed by a qualified and competent manager. Minor improvements to some health and safety aspects will offer further safeguards to residents. EVIDENCE: DS0000025045.V341581.R01.S.doc Version 5.2 Page 24 Mrs. Jenkins has been Registered Proprietor and Manager of The Cedars since it’s opening in 1984. She has extensive experience and is suitably qualified in social care provision. A general manager who also is qualified and competent supports Mrs Jenkins. Feedback received from residents and relatives was extremely positive regarding the management of the Home. For example one relative stated, “nothing is too much trouble, we are always kept informed about any changes or events affecting our mother”. Quality monitoring is excellent at this home. The homes quality assurance policy states views are obtained through comment sheet/cards for relatives, friends and visitors, service user satisfaction surveys carried out regularly and a stakeholder survey. It also states that a Quality assurance report is completed not less than twice a year that reviews analysis of accidents, comments, complaints, CSCI reports and views of people. A random sampling of records confirms that the home is complying with the contents of this policy. Relatives and residents also confirmed that they are regularly asked for their views, which are taken into account when making changes. Systems for the management of resident’s monies are good. Residents are encouraged to manage their own finances if they wish to do so. Generally residents’ relatives manage their finances although small sums of monies are given to the Home on their behalf in order to purchase toiletries or pay for hairdressing. There is a thorough recording method of all financial transactions made with double signatures obtained with the home’s administrator carrying out regular audits. The Home has a facility for the safe keeping of any monies and valuables and there is access to a safe if necessary. The records and finances of three residents were sampled and all found to be accurate. Records required by regulation for the protection of residents are in good order and up to date. The only area where improvements must be made is in submission of notifications in line with Regulation 37 of the Care Home Regulations 2001. During the course of the inspection a number of records detailed incidents that required reporting to the Commission for Social Care Inspection (CSCI) admissions to hospital and falls resulting in injuries. The general manager confirmed notifications had not been made and that the home was using out of date guidance for this. Improvements must be made in this area to ensure residents are protected by the homes recording systems. It is recommended that the home obtain ‘Policy & Guidance: Notification of Death, Illness & Other Events: Regulation 37’ from the CSCI website in order that notifications are completed in line with legislation. Generally health and safety is well managed. Risk assessments are in place for safe working practices, many staff have undertaken training in moving and handling, first aid, food safety and health and safety and all staff are booked to undertake refresher training for fire. Maintenance records for all areas of the building including external, hallways, lounge, dining room, toilets, kitchen, and laundry demonstrate that repairs are carried out within appropriate DS0000025045.V341581.R01.S.doc Version 5.2 Page 25 timescales and a monthly analysis of accidents is completed that details remedial action to reduce risks. The only area where the home was instructed to make improvements was in relation to a bedroom that uses equipment including bedrails. It was the opinion of the inspector that the gap between the rail and mattress appeared excessive with the potential to cause injury. The home was instructed to seek advice from a suitably qualified person regarding this and implement any recommendations made in order to reduce the risk of injury. It was also instructed to complete a detailed risk assessment and complete regular checks on equipment in use until such time as the views of a qualified person have been obtained. DS0000025045.V341581.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 4 X 2 2 DS0000025045.V341581.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement Timescale for action 29/06/07 2 OP37 37 3 OP38 13(4) 4 OP38 13(4) Action must be taken to improve the recording of medication to ensure residents are not placed at risk. Improvements must be made in 29/06/07 submission of notifications in line with Regulation 37 of the Care Home Regulations 2001 to ensure residents are protected by the homes recording systems. The home must seek advice from 29/07/07 a suitably qualified person regarding the gap between the bedrail and mattress for a named resident and implement any recommendations made in order to reduce the risk of injury. Until such time as advice from a 29/06/07 suitably qualified person regarding the bedrail has been obtained the must complete a detailed risk assessment and complete regular checks on equipment in use in order to reduce the risk of injury. DS0000025045.V341581.R01.S.doc Version 5.2 Page 28 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 OP7 OP7 Good Practice Recommendations That where possible residents sign the minutes of the key worker meetings to further evidence their involvement and participation in this process. To promote further the holistic approaches to care management by implementing a format that allows for detailed recording of care needs if a resident develops areas where additional support is required outside of their normal needs. That the date that eye drops and prescribed creams need to be discarded be recorded on the medication administration records as an additional safeguard to residents That the home reviews the amount of medication stored as ‘stock’ as an additional safeguard to residents. That the home obtains syringes in order that accurate measurement of liquid medication can be obtained as an additional safeguard to residents. That the home obtain the Commission for Social Care guidance ‘Administration of Medication in Care Homes’ from its website to ensure the practices and systems within the home meet current good practices guidelines. That greater care be taken to ensure the menu on display accurately reflects choices on offer in order that residents can make informed choices. That further work be undertaken to access specialist training for falls management, tissue viability and continence management in order that staff gains greater knowledge in these areas and to meet the needs of residents. That risk assessments be completed for staff that regular undertake additional shifts to ensure the manager is satisfied they are fit to care for residents and do not pose a risk. That the home obtain ‘Policy & Guidance: Notification of Death, Illness & Other Events: Regulation 37’ from the CSCI website in order that notifications are completed in line with legislation. 3 OP9 4 5 6 OP9 OP9 OP9 7 8 OP15 OP27 9 OP29 10 OP37 DS0000025045.V341581.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Office Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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