Inspection on 19/07/06 for The Cedars (Geoffrey Harris House)

This inspection was carried out on 19th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Cedars (Geoffrey Harris... 16/05/07

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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Edenvale

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Chatsworth Care - Dawson House

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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 19th July 2006 09:30 The Cedars (Geoffrey Harris House) DS0000025845.V303961.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.V303961.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.V303961.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 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 Borders and 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.V303961.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 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.V303961.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 all the key standards and involved a tour of the home, a review of all the homes records and interviews with staff and service users. At the time of this inspection there had been no new service users admitted to the home. There are no vacancies at the home at present. Since the last inspection only 2 of the requirements identified then have been met. One of the previous 2 recommendations has been met. Staff files that had not been inspected at the last inspection were inspected this time. A number of new requirements have been made as a result of this inspection and feedback on all these requirements and recommendations was given verbally to the Registered 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. What the service does well: What has improved since the last inspection? Since the last inspection and a requirement that was made, fire alarm tests have been carried out weekly and appropriate recordings made of these tests. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 6 Evidence of the Criminal Record Bureau checks carried out as a part of the recruitment process has been documented for most staff and was shown to the Inspector at the time of the visit. A bath panel has been replaced in one of the bathrooms. Section 26 visits and incident reports have been sent to the CSCI as required. Autism and Aspergers syndrome training has been provided to staff in the unit as required. A diabetic nurse attended a staff meeting to assist staff in understanding diabetes and the needs of residents with this condition. 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 Cedars (Geoffrey Harris House) DS0000025845.V303961.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.V303961.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users individual needs are being assessed however there could be improvements in the use of service user plans that would benefit service users needs being better met. Not all service users had a written contract and this should be addressed as it can help empower the service user and it represents the formal terms and conditions of the placement. EVIDENCE: The last new service user moved into the home in 2001, there have been no new placements since the last inspection. The last inspection report indicated that prospective service users are provided with sufficient information to make an informed choice about the home and as to how their needs will be met. With respect to standard 3, an inspection of a number of service user files indicated that there are comprehensive needs assessments completed for those service users living at the home. However there were not in all cases up to date service user plans in place. This may mean that not all the information identified in the needs assessments is being considered in the actual delivery of care to the service users. One service user who had experienced problems travelling into Croydon had been assessed as needing additional support and although he was receiving support there was no structured care plan identifying how this support would be offered, monitored or how the outcomes The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 9 would be reviewed. It is therefore now a requirement that in all cases for each service user there is an up to date service user plan that relates to the needs assessments and which supports service users needs to be met most effectively as well as assisting keyworker staff to work most effectively with their service users. Where appropriate service users views, wishes and preferences should also inform these service user plans. The Inspector inspected 3 service user files and only on 1 of these files was there an individual written contract. It is recognised that the majority of the existing residents have been living at the home for several years, however it is necessary for each resident to have their own contract with the service. This is a requirement. Each resident should have a copy of the contract along with a copy of their service user plan and the Service User Guide for the home. It is recommended that a folder be provided for each service user which contains this information and which can be kept in the service users rooms. The registered Manager informed the Inspector that the areas of training identified in the last report have now been delivered to staff appropriately. included training on autism and aspergers syndrome. The Cedars (Geoffrey Harris House) DS0000025845.V303961.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users are able to make decisions about their lives with assistance as needed, however risk assessments need to be updated if service users are to be better supported to take risks as part of an independent lifestyle. EVIDENCE: 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. However as indicated in the previous section not all service user files contained an up to date service user plan based on the most recent professional assessments and reviews. Therefore service users cannot be fully assured their assessed and changing needs and personal goals are reflected in their individual plans. Requirements have been made in the previous section relating to this. Interviews with 4 of the 6 service users confirmed that service users do feel they are able to make decisions about their lives with assistance as they need. Service users told the Inspector that they are involved in their own meetings The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 11 and this was also confirmed by 2 of the staff interviewed by the Inspector as part of the inspection process. All service users have a My Plan (Person Centred Plan) in place and these plans include My Relationship Circle, How I Communicate, Individual Risk Assessments and My Dreams. These plans seen by the Inspector were however undated and so it was not possible to know whether the “My Plans” are up to date. It is recommended that in future all “My Plans” be dated and a review dated marked down on the plan. This should ensure that these plans take into account the changing circumstances and views of service who should sign (where appropriate) the plans to demonstrate their agreement to them. Following training on Person Centred Planning some staff and service users have completed or are completing Person Centred Plans. Two of these plans were examined. The plans included 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. The 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. However up to date risk assessments for each of the service users were not seen on the files examined by the Inspector. It is therefore a requirement that risk assessments for all service users are updated and are included in the service user plan and are agreed with the service user, 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. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. 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. Provision is made so that all service users attend appropriate social activities, day centres and become part of the local community. Service users are enabled to have appropriate relationships. Appropriate arrangements are made so that all service users have regular contact with their friends and families. EVIDENCE: Some service users told the Inspector that they travel independently into Croydon to go shopping or to go to the cinema. Other service users need support to access the community. One service user said he works on Mondays and Wednesdays at Croydon Cemetary as a gardener. Two other service users told the Inspector that they attend Croydon College completing courses on Making Pictures, Woodwork, IT and Skills Link. Another service user attends aqua aerobics and another attends a sports group on Fridays. Service users are also supported to visit local cafes, cinemas, and swimming pools and go on daytrips in the homes minibus. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 13 All service users have strong family links, some service users 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. The Registered Manager told the Inspector that service users hold regular meetings and minutes of these meetings were seen in a record book. It was evident from the minutes that service users are given an opportunity to express their wishes and concerns at these meetings. The homes menus seemed varied and nutritious in content, are based on a four-week rota and are checked by a dietician for nutritional balance. The Service users 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. One of the service users has Diabetes’s and is on a low fat/low cholesterol diet. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. The homes policies and procedures for handling medicines ensure the service users are so far as reasonably practicable protected from harm and/or abuse, however recording practices for the administration of medication need to be improved. EVIDENCE: Service users do receive personal support in the way they prefer and require. Service users interviewed by the Inspector said that they are mostly able to make decisions about their daily lives as they would wish. However not all service users were entirely clear about their care plan objectives and thus the requirements relating to PCPs and risk assessments that have been made to meet this need that have been identified in previous sections of this report. The inspection of the service user files did not evidence any health action plans being in place for service users. These plans should identify healthcare needs and what guidance and support is needed for each resident. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 15 All residents have access to appropriate health professionals as required and evidence of input for service users from these professionals was seen on service user files. Some service users told the Inspector that they do retain control over some of their medications and this was confirmed by staff and indeed by the homes records. The home has the support of a local pharmacist for advice on medication. Medication is stored in a locked cupboard in the dining room. Medication administration records checked on the day of the inspection were up to date and were mostly accurate. However there were some unfilled spaces for 3 of the service users records (MAR sheets) seen by the Inspector. These gaps in recording were acknowledged by staff interviewed. The Medical Records Card (MRC) used by the home also showed some missing information. The Registered Manager explained to the Inspector that the home is required to use the MRC by the NHS Trust and when the information is transferred from MAR sheets to MRC cards this may be where some information was not included. It is a requirement that all medical records are fully completed especially the recording on MAR sheets of the daily administration of medication to residents. 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 however not all the staff interviewed by the Inspector have attended this training and it is a requirement that all staff involved with medication administration receive this training and regular update training. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 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. The home has appropriate complaints and adult protection procedures procedure in place however provision of staff training in the Protection of Vulnerable Adults should be improved. EVIDENCE: The Registered Manager supplied the Inspector with the complaints record book and the policies and procedures for making and dealing with complaints. No complaints had been recorded in the record book since June 2003. The Complaints procedure is appropriate and meets the expected standard. Service users told the Inspector that they do feel their views are listened to and are also acted upon. With reference to the training provided for staff to do with the Protection of Vulnerable Adults (POVA), the inspection of staff files and the interviews with staff identified that not all of the current staff group have received POVA training. Evidence seen by the Inspector on staff files showed that those staff who have been POVA trained received their training in 2004.This staff training should be updated more regularly (at least every 2 years) especially given the needs of the residents now living within the home. It is therefore required that all staff receive POVA training and refresher training every 2 years. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. The overall impression when visiting this home is that it is clean and hygienic however attention should be paid to the homes décor in particular the downstairs hallway and the bathrooms thus ensuring the service users live in a more homely and comfortable environment. EVIDENCE: 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. The bathrooms are still in need of refurbishment despite previous requirements having been made by CSCI. The bath panel in one of the bathrooms has been replaced however the skirting boards have not been replaced and are beginning to rot due to surface water. The flooring in the upstairs bathroom is badly water marked and is coming away from the walls and the edge of the bath. It remains a requirement therefore that the Registered Manager The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 18 must ensure that both the homes bathrooms are refurbished. The Service Manager was on site for a part of the inspection visit and the Inspector raised the issue of this requirement not having been met within previous timescales. The Service Manager was able to give an assurance that both bathrooms and the hallway will be refurbished as required within the next 3 months. This was also confirmed by the Works Supervisor from the NHS Trust who was on site during the inspection visit. It has been noted in the last three inspection reports that the bottom corner of a wall in the downstairs hallway is chipped, and recommendations were set that the home manager protect the corners with plastic covers however despite assurances from the previous home manager at the inspection in October 2004 this work has never been completed. The paintwork on the wall outside one of the service users bedrooms in this hallway has also deteriorated. The home manager must ensure that the downstairs hallway is redecorated. The home was clean, tidy and free from offensive odours at the time of the inspection. The home has appropriate laundry facilities. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 36. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users cannot be fully assured that they are fully protected by the recruitment practices nor that staff are being regularly supervised in their working roles. EVIDENCE: Over the course of this inspection the Inspector saw that staff do take time to deal with service users questions. Staff were seen to be approachable and service users obviously felt able to look to staff for advice and support as required. A programme of NHS staff training is available for all staff that covers the essential areas needed for staff to carry out their roles appropriately. A process of training needs analysis for each member of the staff group would be helpful to ensure that all staff have their training needs met in order to meet the needs of the residents. It is recommended therefore that a training needs analysis is put into place as a part of the supervision process for staff. Only 4 of the existing staff group of 12 have an NVQ 2 qualification and the Inspector advised the Registered Manager of the requirements under Standard 32.5 about 50 of the staff group needing to hold an NVQ qualification. The Registered Manager informed the Inspector that there has been over the last 6 The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 20 months considerable changes in the staff working in the home. However now that this is more settled staff will be enrolled for NVQ training this Autumn. Given previous requirements to do with all staff having appropriate Criminal Record Bureau Checks the Inspector requested from the Registered Manager evidence that these checks have now been carried out. CRB clearances have been provided for all but 2 staff, one of whom is due to leave in the near future. The Registered Manager informed the Inspector that neither staff have been working alone with service users and the Inspector advised the Registered Manager and the Service Manager that under no circumstances should staff without a valid CRB check be allowed to work with any service users unsupervised at any time. It is a requirement that all staff have a CRB and POVA Enhanced clearance check and that a record of the valid clearance is held on staff files within the home. This applies to 1 member of staff given that the other relevant staff member is due to leave very soon. If circumstances change and that member of staff does not leave then they too will need a valid CRB check. The recruitment process in use for this home is that of the overall NHS Trust and the required documents that evidence how the process is carried out are held on staffing files. Inspection of these documents showed that the recruitment process is satisfactory and that on the whole service users are protected by the home’s recruitment policy and practices. Staff have not yet had their annual appraisals and both the Registered Manager and the Service Manager informed the Inspector that annual appraisals can only proceed once the Trust’s KSF (knowledge and skills framework) procedures have been introduced across the Trust. The timetable for the rollout of this starts this August 2006. Once Managers have been trained then staff will receive their appraisals. A requirement was set at a previous inspection that 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 some staff have not received regular supervision within the prescribed timescales. This means that service users cannot be assured that they will benefit from well supported and supervised staff. Staff supervision records showed that some staff have not had any formal supervision in 2006 and staff interviewed acknowledged this to be true however they told the Inspector that they have received informal supervision when they needed it. The supervision records that were seen over the inspection were too brief to demonstrate that all the necessary elements of supervision are being carried out satisfactorily. These elements should include: • the translation of the homes philosophy and aims into work with service users; • the monitoring of all work with individual service users; The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 21 • • • support and professional guidance appropriate for the staff members needs ; identification of training needs and development needs; an appraisal system. It is a requirement therefore that all staff are supervised at least once every 6-8 weeks and that proper recording of all the areas discussed are documented including all the targets and objectives made and the timescales in which they are to be achieved and whether or not they have been met or not. Supervision sessions should include the review of the service users careplan objectives where staff being supervised have keyworker responsibilities for service users. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the inspection visit to this service. Service users cannot be fully assured that they will benefit from a well run home. They also cannot be fully assured that their views underpin all selfmonitoring review and development by the home. EVIDENCE: Since the last inspection the Manager has recently become successfully “registered” as a manager with the CSCI. The Registered Manager informed the Inspector that with regard to a quality assurance process the views of service users has been sought in the past however this has not been extended to families or relevant professionals including the referring professionals. Information gathered from the service users has not been analysed or evaluated. When the Inspector looked at the questionnaires completed by service users they were not dated so it was impossible to be able to tell when this information was gathered. There The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 23 followed a discussion with the Registered Manager about how a Quality Assurance system could work and how it could usefully contribute to the development of the unit and improve services for the residents. During the inspection in October 2004 evidence was seen by that Inspector of a newly devised QA system. It included questionnaires for using with service users, families and relatives, referring professionals and visitors. It was said that the previous home manager had had plans to employ this in the home. At the time of the last inspection there was no evidence to suggest that these questionnaires had been completed and it was recommended then that the new home manager use this QA system within the unit. At this inspection the Registered Manager told the Inspector that he had no knowledge of the October 2004 QA system but said “that it could have been developed by a previous manager”. The Registered Manager agreed to look at this system, review it and put a new QA process into place for the unit. It is a requirement that an appropriate QA process is put into place for this unit which provides sufficient appropriate information to be of use in improving services for the residents. Policies were seen by the Inspector for Health and Safety; fire; moving and handling and risk assessment relevant to the unit. The Registered Manager informed the Inspector that all staff have been asked to read these policies and procedures and sign to say that they have read, understood and are prepared to work within them. However not all staff have signed the Fire policy to say that they have read, understood them and are prepared to work within them. This is a requirement. Most of the staff have received training in moving and handling; fire safety; first aid; food hygiene and infection control. The Registered Manager should ensure that all staff have undertaken recent training in these areas. Up to date certificates were seen for the appropriate checks and requirements within Standard 42 of “safe working practices”. On the tour of the premises a senior member of staff accompanied the Inspector. Inspection was made of how hazardous materials are being stored in the unit bearing in mind the COSSH guidelines. Most cleaning materials are being stored safely however a cupboard in the kitchen in which were stored cleaning materials was unlocked at the time of inspection and could have presented a hazard to a resident entering the kitchen. It is a requirement that all hazardous materials are always and consistently locked in secure cupboards. Following the last inspection, fire alarm tests are now being carried out weekly and these checks are recorded on paper appropriately. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 24 A check of the fire extinguishers revealed that some had not been tested since October 2005. The units own procedures classify this as “portable fire equipment” and require 3 monthly checks. It is requirement that all portable fire equipment is in fact tested professionally every 3 months including fire extinguishers. 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.V303961.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 2 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 2 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 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 1 X X 2 X The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes and they are shown in bold below. 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 YA27 Regulation 23(2) b. Requirement The home manager must ensure that both the homes bathrooms are refurbished. Previous timescale not met. The home manager must ensure that the downstairs hallway is redecorated. Previous timescale not met. The acting home manager must ensure that each member of staff completes an annual Appraisal. Previous timescale not met. Each service user should have an up to date service user plan. Each service user should have their own contract with the service. Risk assessments for all service users should be updated and included in the service user plan and agreed with the service user, their families and relevant professionals. All medical records are to be fully completed especially the recording on MAR sheets of the daily administration of medication to residents. All staff involved with medication DS0000025845.V303961.R01.S.doc Timescale for action 01/10/06 2 YA24 23(2) d. 01/10/06 3. YA35 18(1) c. 30/11/06 4. 5. 6. YA3 YA5 YA9 15(2) 5(1)C 14 01/11/06 01/10/06 01/11/06 7. YA20 13(2) 01/08/06 8. YA20 13(6) 01/12/06 Page 27 The Cedars (Geoffrey Harris House) Version 5.2 9. 10. YA23 YA34 13 19.1.b 11. YA36 18 12. YA39 24 13. 14. YA42 16 23 YA42 15. YA42 23 administration should receive training and regular update training. All staff should receive POVA training and refresher training every 2 years. All staff should have a CRB and POVA enhanced clearance check and a record of the valid clearance is held on staff files within the home. All staff to be supervised at least once every 6-8 weeks and records made of all the areas discussed including all the agreed targets and objectives and the timescales in which they are to be achieved and whether or not they have been met or not. Supervision sessions should include the review of the service users careplan objectives where staff being supervised have keyworker responsibilities for service users. An appropriate QA process should be put into place which provides sufficient and appropriate information of use in improving services for the residents. All hazardous materials must always and consistently be made secure. All portable fire equipment is tested professionally every 3 months including fire extinguishers. Staff must sign the Fire policy to say that they have read, understood them and are prepared to work within them. 01/12/06 01/09/06 01/08/06 01/10/06 01/08/06 01/09/06 01/09/06 The Cedars (Geoffrey Harris House) DS0000025845.V303961.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. 3. 4. Refer to Standard YA39 YA6 YA36 YA3 Good Practice Recommendations that the new home manager employ’s a service user, service user relatives and visitors questionnaire/survey in the home. that in future all “My Plans” be dated and a review dated marked down on the plan. that a training needs analysis is put into place as a part of the supervision process for staff. That a folder be provided for each service user which contains this information and which can be kept in the service users rooms. The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Cedars (Geoffrey Harris House) DS0000025845.V303961.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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