Inspection on 16/05/07 for The Cedars (Geoffrey Harris House)

This inspection was carried out on 16th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Cedars (Geoffrey Harris... 19/07/06

The Cedars (Geoffrey Harris... 21/09/05

The Cedars (Geoffrey Harris... 19/05/05

The Cedars (Geoffrey Harris... 25/10/04

The Cedars (Geoffrey Harris... 13/04/04

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 The Cedars (Geoffrey Harris House) Geoffrey Harris House Coombe Road Croydon Surrey CR0 5RD Lead Inspector David Halliwell Key Unannounced Inspection 16th May 09:30 The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Cedars (Geoffrey Harris House) DS0000025845.V336770.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 (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars (Geoffrey Harris House) Address Geoffrey Harris House Coombe Road Croydon Surrey CR0 5RD 020 8680 1593 020 8681 8554 david.bosworth@sabt.nhs.uk 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) Surrey and Borders Partnership NHS Trust Mr David Bosworth Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2006 Brief Description of the Service: The Cedars is a residential home offering support for up to six service users with learning disabilities and associated challenging behaviours. It is owned managed and staffed by Surrey and Borders NHS Trust. The Cedars is in a semi rural setting in a campus style shared by a day service and other residential homes. It is close to Lloyd Park and local transport including a tram-link to Croydon town centre. The home also has a minibus enabling service users to access other community facilities. The Cedars is a six bed-roomed house with a communal lounge, dining room, kitchen and small office. The home also has a small well-maintained garden. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The Inspection covered the key standards and involved meeting with the Deputy Manager given that the Manager was on a days leave. A tour of the home, a review of all the homes records and interviews with residents were also integral parts of the inspection. At the time of this inspection there had been no new service users admitted to the home and no new staff members. There are no vacancies at the home at present. 1 requirement remains unmet and 3 recommendations have been made as a result of this inspection and feedback on the requirement and recommendations was given verbally to the Deputy Manager at the end of the inspection visit. The Inspector found the residents and staff very helpful and they are to be thanked for the assistance that they gave him over the course of this inspection visit. At the last inspection the Manager informed the Inspector that the standard fees for a standard residential placement at this home are £600 per week. What the service does well: As stated at the last inspection the home appears to meet the needs and wishes of the residents and the management approach of the home creates a positive and inclusive atmosphere. The home offers residents opportunities to participate in the day-to-day running of the home and they are able to express their wishes and concerns in a confident manner. Residents have opportunities to attend employment, education, and daytime activities, social activities are generally very good and service users are encouraged and supported to be as independent as possible. The arrangements for health care needs of the service users are good and the home has the support of a local pharmacist for advice on medication. Arrangements are also made so that all service users have regular contact with their friends and families. Residents are living in a safe, well-maintained environment, with access to safe, pleasant and comfortable facilities. The home is being managed the home in an open, professional and competent manner. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 - Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users individual needs are being fully assessed and their individual views and wishes form an integral part of this process. EVIDENCE: Standard 2 – At this inspection 2 of the 6 residents files were inspected. A full needs assessment had been completed and was seen on the files for each of these residents. The assessments cover all the main areas of individual need and were comprehensive in this coverage. Where appropriate service users views, wishes and preferences have been included as part of the needs assessments and also in the service user plans. In each of the files inspected there is now an individual written contract with a yearly update provided by the NHS Trust as to the level of fees being charged. This marks a development since the last inspection and it is positive that residents now have a copy of the contract on their files. A revised and updated Service User Guide was completed in April 2007 that provides a useful and informative handbook for residents. On reviewing the resident’s files, the Inspector found a very positive and marked improvement in the order and filing of the information about each of The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 9 the residents. The Manager and staff are to be commended on this development that should greatly assist them with the support and care of the residents. Information was seen to be logically and chronologically ordered with appropriate information section within the files. The Cedars (Geoffrey Harris House) DS0000025845.V336770.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): Standards 6, 7 & 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that their assessed and changing needs are reflected in their care plans and are able to make decisions about their lives with assistance as needed. Newly reviewed and updated risk assessments will assist residents to be better supported to take risks as part of developing a more independent lifestyle. EVIDENCE: Standard 6 - On both of the resident’s files inspected this time there was a service user plan that had been updated and reviewed in the last 6 months. Given the residents needs being provided for at The Cedars, the most appropriate tool to be used is that of the “My Plan” which is based on a Person Centred Planning approach. The Deputy Manager told the Inspector that each of the residents play a central role in the drawing up of these plans and that The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 11 they remain the key focus of the 6 monthly reviews and updates made to the “My Plans”. During the course of this inspection 3 of the residents enthusiastically showed the Inspector their “My Plans” clearly demonstrating their involvement and ownership of these plans and the importance of the plans and the care plan objectives, to them. On inspection of the “My Plans” / care plans they were seen to include photographs of the service users involved in domestic and social activities such as cooking, laundry, trampoline, holidays and other social events. The plans also included pictures of the service users friends and family, activity charts and action plans. These plans also include treatment needs; the needs and goals of the resident; specific areas of support needs; specialist requirements; communication and challenging behaviour needs; behaviour plans; likes and dislikes including individual preferences both for social activities and other areas of living such as food and clothing. The plans evidently had been drawn up with the resident and with other key people such as relatives and professionals involved in the residents lives. It was also clear that the referring care managers had, in the most part, a continuing involvement in the care planning process and do as an example attend annual reviews. In one case file seen by the Inspector however there is a need for that Care Manager to update this process for their resident. The appropriate documents identified in Schedule 3 of the National Minimum Standards were all seen by the Inspector to be held on service user files. Informal interviews with 3 of the 6 residents confirmed that they do feel they are able to make decisions about their lives and get assistance, as they need it. Residents told the Inspector that they are involved in their own meetings and this was also confirmed by staff interviewed by the Inspector as part of the inspection process. All of the above marks a significant improvement made by this unit in the overall care planning since the last inspection and service users can be fully assured their assessed and changing needs and personal goals are reflected in their individual plans. Previous requirements that were made have now been met. Standard 7 - This Standard refers to the ability of residents to make decisions about their lives and to get assistance, as they need it. So in addition to the points already made above, over the course of this inspection the Inspector saw staff respecting residents rights to make their own decisions and to make individual choices in their daily lives. The Deputy Manager told the Inspector that residents have their own monthly meetings where they talk about any issues and service developments they wish to discuss, as an example they regularly talk about menus and what changes they would like to be made and most recently about their choice and The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 12 preferences for their annual holidays. The Inspector saw the minutes for these meetings that detailed these discussions and supported the information given by the Deputy Manager. Residents also confirmed with the Inspector the usefulness of their monthly meetings. Standard 9 - Inspection of the service user files by the Inspector revealed that risk assessments had been undertaken at the time of the service users admissions to the home and following a requirement made at the last inspection have now been reviewed and updated. These risk assessments were seen to have been agreed with the resident, their families and relevant professionals. Appropriate risk assessments help service users to be supported to take risks as a part of developing an independent lifestyle and so this is a positive development for the residents at The Cedars. The Cedars (Geoffrey Harris House) DS0000025845.V336770.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): Standards 13, 15, 16 and17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents are able to take part in age and culturally appropriate activities and are to a reasonable extent involved in local activities. Residents have appropriate relationships and their rights and responsibilities in their daily lives are recognised and respected by the staff in the unit. Residents are offered a healthy and varied diet from a menu that they assist in drawing up. EVIDENCE: Standard 13 – The Deputy Manager told the Inspector that residents at the Cedars do have a relatively active social life and are involved in community activities that interest them. Examples were given of residents attending “ The Beautiful Octopus Club” at Croydon’s clock tower. This is a club that has a disco, karaoke and a bar and residents enjoy going to this club meeting every The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 14 3 months where they may meet other people and enjoy themselves. The Inspector was informed that residents also go swimming regularly in Addington, trampolining in Caterham, and often go with staff to pubs and coffee bars in and around Croydon. During the course of this inspection the Inspector spoke to all the residents, some of who told the Inspector that they do travel independently into Croydon to go shopping or to go to the cinema. Other residents need support to access the community. One resident said he works on Mondays and Wednesdays at Croydon Cemetery as a gardener. Two others told the Inspector that they attend Croydon College completing courses on Making Pictures, Woodwork, IT and Skills Link. Residents said that they enjoy going to visit local cafes, cinemas, and swimming pools and go on daytrips in the homes minibus. Standard 15 – The Deputy Manager told the Inspector that all the residents have strong family links; some go home for weekend stays and visits. There is an open visitors policy and the home just ask that visitors phone to ensure their family member is going to be in before they visit. Staff support residents appropriately where they need it and where they have girlfriends/boyfriends. Appropriate professional help such attendance at a men’s group and other support groups is given and has clearly assisted one male resident in developing and maintaining his relationship with his girlfriend. This means that residents may have appropriate personal, family and sexual relationships and be supported appropriately in maintaining these relationships where they wish. Standard 16 - Policies seen by the Inspector to be established within the home ensure that service users rights to privacy, respect and dignity are respected. Residents who were interviewed also confirmed that they felt staff respected these rights. Residents said that they have a key to their own bedrooms, their mail is unopened, their preferred form of address is used by staff and staff do knock on their doors before entering. The Inspector observed staff to be interacting with residents in a friendly and respectful manner. All the residents are able to spend time on their own and are actively supported by staff where appropriate to do so. The Deputy Manager gave the Inspector an example of this where for instance 1 resident who suffers from seizures likes to spend time in his own company but needs to be regularly checked by staff in case he has a seizure. In this instance staff will check every half hour by knocking on his door but do not enter unless they are needed. Residents also participate in the household chores such as washing their clothes and keeping their rooms clean and tidy. Residents told the Inspector that they enjoy these tasks and seemingly take them seriously. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 15 Standard 17 - With regards to meals and meal times there is a planned and varied menu which residents told the Inspector they enjoy. The Inspector saw suitably planned menus for the week ahead. Specific needs are catered for and alternative choices are provided. Residents are able to state their preferences when the menus are planned and there are discussions about this at the residents community meetings, which are held monthly. The homes menus seemed varied and nutritious in content, are based on a four-week rota. The Deputy Manager told the Inspector that wherever a resident has special dietary needs, support can be requested from a dietician who will also assist in drawing up appropriate menus. Residents told the Inspector that they are offered an alternative to the main meal on offer and the Inspector witnessed staff asking service users what they preferred to eat on the day of the inspection. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 16 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): Standards 18, 19 & 20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Residents can be assured that they will receive personal support in the way that they prefer and require. Their physical, emotional and health care needs will be met. Residents can rely on the home providing a well-managed service with regards to medication and that they will be protected by the home’s policies and procedures for dealing with medications. EVIDENCE: Standard 18 - Service users do receive personal support in the way they prefer and require. Service users interviewed by the Inspector said that they are able to make decisions about their daily lives as they would wish and feel that they are supported in an appropriate and helpful way. Staff interviewed also explained to the Inspector their approach to the personal support and care that they provide to the residents. This supports the view that service users do receive personal support in the way they prefer and require The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 17 Standard 19 – The Deputy Manager told the Inspector that each resident now has a healthcare plan that is regularly reviewed in conjunction with medical services (e.g. GPs) to ensure that the resident’s needs are met appropriately. Records examined confirmed that arrangements are in place for meeting resident’s healthcare needs. They are supported to access a range of NHS facilities e.g. GP, Consultant, dental, chiropody, optician and physiotherapy services. “Health action plans” were seen to be in place for each resident as described by the Deputy Manager. Regular health checks are conducted for each resident every 6 months. Information relating to personal and healthcare needs including both routine and one off health interventions were well recorded. Care plans and specific strategies identify individual and specialist needs, which also reflect any changing needs. Detailed records were in place and involvement with specialist services highlighted where necessary. Standard 20 - The home has the support of a local pharmacist for advice on medication. The pharmacist also provides regular audits to the home to further ensure that medication practices are undertaken appropriately. Records showed that no concerns have been highlighted. Medication is stored in a locked cupboard in the dining room and controlled drugs are now being stored in a locked metal cupboard within that locked metal cupboard. The Inspector together with the Deputy Manager carried out a spot check to see if the medication administration records reflected the current medication stocks. 4 different medications were checked and the stored medication stocks matched the records, thus indicating that the home’s procedures for medication administration are being implemented appropriately. Other medication administration records (MAR sheets) checked on the day of the inspection were up to date and were accurate with no unfilled spaces on the MAR sheets seen by the Inspector. A previous requirement that all medical records be fully completed has now therefore been met. The medication administration system includes a service user medication profile and a service user photograph. There are guidelines for staff to follow prior to administering as required medication. Each service user has a signed “consent to medicate” form. The home has a medication policy and procedure. The Surrey and Borders NHS Trust provides accredited training in the administration of medication in line with the policy and the Deputy Manager told t he Inspector that all staff who administer medication to residents have and are required to have by the NHS Trust training updated every 2 years. A previous requirement that all staff involved The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 18 with medication administration receive this training has now therefore been met. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 19 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): Standards 22 & 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Arrangements for complaints and protection from abuse are well managed and ensure that service users feel listened to and safe. EVIDENCE: Standard 22 – The Deputy Manager informed the Inspector that no complaints had been received since the last inspection visit. The complaints procedure contains all of the relevant and necessary information and is readily available to the residents, their relatives and other visitors. A log of complaints is kept in a book and no complaints had been made about the home since the last inspection. Service users are aware of who to go to if they feel unhappy and are provided with the necessary support to air their views or concerns. Service users told the Inspector that they do feel their views are listened to and are also acted upon. Standard 23 – At the last inspection a requirement was made that all staff should receive POVA training so as to ensure that all service users are protected from abuse, neglect and self-harm. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 20 The Deputy Manager told the Inspector at this inspection that some progress has been made with getting staff onto this training and a review of 3 of the staffing training files showed that they had received training in 2006. However some staff still need this training to be updated so that all staff receive a refresher at least once every 2 years especially given the needs of the residents now living within the home. It is therefore recommended that the Manager and the Service Manager ensures that all staff can access POVA training and receive refresher training every 2 years. The Cedars has an Adult Protection policy and a copy of this was seen by the Inspector in the policies and procedures file. The home’s policies and procedures cover all essential areas of guidance, including physical intervention, service user’s finances, insurance and such issues as gifts gratuities and bequests. There are sufficient organisational policies to safeguard the residents’ welfare e.g. dealing with abuse and a whistle blowing policy. The Deputy Manager told the Inspector that all staff members are all thoroughly vetted and recruitment assures that nobody starts at the home until their credentials with regard to the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults Register have been checked. At the previous inspection the Inspector reviewed all the staffing files and found the recruitment checks referred to by the Manager had been carried out as specified. The Inspector was not able to see the actual CRB certificates at this inspection as they were locked away in the safe and only the Manager has a key. However the Deputy Manager confirmed there have been no new staff members in the home and all the documentation was seen as correct at the last inspection. The Deputy Manager told the Inspector that no allegations of abuse had been received since the last inspection and the record book seen by the Inspector confirmed this. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 21 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): Standards 24 & 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may be assured that they do live in a safe and comfortable house that is also clean and hygienic. EVIDENCE: Standards 24 & 30 - The Cedars is a two storey six-bed roomed house with a communal lounge, dining room, kitchen, laundry, small office and a garden. The home is suitable for its stated purpose. Each service user has a single room, which is decorated and personalised to reflect their individual taste. The home has one individual toilet and two multipurpose bathrooms. Since the last key standards inspection the bathrooms have now been fully refurbished, a bath panel in one of the bathrooms has been replaced and so have the skirting boards been replaced. The hallway downstairs has also been The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 22 refurbished as required at the last inspection. Therefore the previous requirement has now been met. The Manager, Service Manager and the Works Supervisor from the NHS Trust are to be thanked for ensuring this work has now been completed. The home was clean, tidy and free from offensive odours at the time of the inspection. The home has appropriate laundry facilities. Following this inspection it is recommended that the floor of the kitchen be replaced, as it is starting to deteriorate and may well present a health hazard to residents. Also the coloured chopping boards in the kitchen need to be replaced as they are old and their surfaces are badly scored. A visit by the Environmental Health Officer in February 2007 complimented the home on its high standards being maintained and made no requirements. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 23 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): Standard 32, 35 & 36. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users may now be fully assured that they are fully protected by the recruitment practices and that staff are being regularly supervised in their working roles. EVIDENCE: Standard 32 – The Deputy Manager informed the Inspector that at the present time, 2 of the existing staff group of 12 do not have an NVQ at least at level 2. 1 other member of staff is trying to undertake an NVQ 3 but has found it very difficult to get onto the training. The Inspector advised the Deputy Manager of the requirements under Standard 32.5 as to how this year all of the care staff group will need to hold an NVQ qualification at level 2. The Deputy Manager is herself an NVQ assessor and said that arrangements will be made to ensure that these staff do get the required training. This is a requirement so that residents may be assured that they are supported by competent and qualified staff. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 24 Standard 35 – A review by the Inspector of 5 staff training files demonstrated that staff have had their annual appraisals in September 2006. At the last inspection the Registered Manager and the Service Manager informed the Inspector that annual appraisals would proceed once the Trust’s KSF (knowledge and skills framework) procedures have been introduced across the Trust. The Deputy Manager told the Inspector that this has now been done and so staff are receiving their appraisals. New training files have been introduced since the last inspection for members of staff and they include their details of training achieved and their certificates. The Deputy Manager showed the Inspector these files which are a useful tool to assist in meeting the training needs of the staff. The Deputy Manager told the Inspector that staff receive regular training in fire safety; first aid; food hygene; POVA; the safe handling of medication and medication administration; managing challenging behaviour, violance and aggression and fire safety. Evidence of this was seen in the staff training files and was also supported by staff to whom the Inspector spoke at this inspection visit. Standard 36 - All staff should receive regular supervision at least eight times a year or once every six weeks. Inspection of the staff records and interviews with staff showed that staff do now receive regular supervision within the prescribed timescales. This means that service users can be assured that they will benefit from well supported and well supervised staff. Staff supervision records seen by the Inspector showed that staff have had this formal 1:1 supervision up to the time of this inspection visit. Managers are reminded now of the need to maintain this supervision practice. Staff interviewed acknowledged that they have received supervision but also told the Inspector that they have received informal supervision when they need it. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 25 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): Standards 39 & 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the inspection visit to this service. The Manager and the staff work hard to ensure that service users benefit from a well run, competently managed, open and safe environment. With the development achieved in the quality assurance system residents can be assured that their views and the views of other relevant people will underpin the monitoring and review of the developments within the home. Service users can be assured that their welfare, health and safety is safeguarded through the home’s adherence to appropriate guidance and regulations concerning best safety practice. EVIDENCE: Standard 39 - At this inspection the Deputy Manager told the Inspector that since the last inspection feedback surveys have been developed and sent out The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 26 to relatives, residents and visitors to the home. The Inspector saw examples of the survey forms and a quality management analysis sheet and an action plan format have also been developed. The Inspector recommends that in addition to these feedback sheets a new feedback be also sought from professionals who work with the residents, including care managers. This would be a useful source of feedback for the home in the process of self-monitoring, review and development of the quality assurance process. Unfortunately the quality management analysis sheets and action plan sheets have not been used since the last survey was carried out in 2006. This means therefore that elements of the feedback may not have been fully utilised in the process of self-monitoring, review and development of the quality assurance process. A requirement was made at the last inspection visit that an appropriate QA process be put into place that provides sufficient appropriate information to be of use in improving services for the resident. This requirement has partially now been met however although the process has been developed and used, the need for analysis remains and so this becomes a recommendation to implement with the next survey this year 2007. Standard 42 - Policies were seen by the Inspector for Health and Safety; fire; moving and handling and risk assessment relevant to the unit. Most of the staff have received training in; fire safety; first aid; food hygiene and infection control. The Registered Manager should ensure that all staff has undertaken recent training in these areas (see also Standard 35 above). The Inspector asked the Deputy Manager to see up to date certificates for maintenance and the appropriate checks and requirements within Standard 42 of “safe working practices”. 1. Boiler / gas 2. Electrical system 3. Fire alarms – tested as satisfactory on 12.5.07 4. Emergency lighting – 24.4.07 5. Fire doors – 12.5.07 6. Fire extinguishers 7. Portable electrical appliances 8. Other equipment. Unfortunately these records were not in good order and it was difficult to find the appropriate records required to evidence that the appropriate checks and requirements within Standard 42 of “safe working practices have been carried out. It is therefore strongly recommended that the Manager ensure all these records are sorted and filed so that they are easily accessible and the appropriate information is made available to ensure that the The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 27 appropriate checks and requirements within Standard 42 have been carried out. On the tour of the premises made during this inspection the Inspector saw that hazardous materials are now being stored appropriate to the COSSH guidelines. Most cleaning materials are being stored safely in a locked cupboard in the laundry. Materials stored in a cupboard in the kitchen (cleaning materials) were locked at the time of inspection. A previous requirement that all hazardous materials are always and consistently locked in secure cupboards has now therefore been met. Following the last inspection, fire alarm tests are now being carried out weekly and these checks are recorded on paper appropriately. There are appropriate policies and procedures for accidents and incidents and all incidents and accidents are recorded appropriately in record books – nothing recorded since the last inspection. Records for the regular testing of the temperatures of all the homes hot water outlets was also seen by the Inspector as satisfactory. Other records were also seen for: 1. Weekly fire alarm tests 2. 6 monthly emergency lighting tests 3. 6 monthly fire drills 4. Fridge and freezer temperatures. The home has self-monitoring systems in place such as internal audits and regulation 26 visits. Service users hold regular meetings and it was very evident from the minutes that service users are given an opportunity to express their wishes and concerns at these meetings. Service users spoken to on the day of the inspection said that they feel that staff and managers in the home listen to them and generally comply with their requests. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 3 X X 3 X The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 29 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 YA32 Regulation 18 Requirement All of the care staff group will need to hold an NVQ qualification at level 2 so that residents may be assured that they are supported by competent and qualified staff. Timescale for action 30/03/08 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 YA23 Good Practice Recommendations That the Manager and the Service Manager ensures that all staff are able to access POVA training and refresher training every 2 years. Following this inspection it is recommended that the floor of the kitchen be replaced, as it is starting to deteriorate and may well present a health hazard to residents. Also the coloured chopping boards in the kitchen need to be replaced as they are old and the ir surfaces badly scored. An appropriate QA process of analysis should be put into place that provides sufficient and appropriate information of use in improving services for the residents. YA24 3. YA39 The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 30 4. YA42 That the Manager ensures all the maintenance records are sorted and filed so that they are easily accessible and the appropriate information is made available to ensure that the appropriate checks and requirements within Standard 42 have been carried out. The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 The Cedars (Geoffrey Harris House) DS0000025845.V336770.R01.S.doc Version 5.2 Page 32 - 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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