Inspection on 23/05/06 for Welcome House - The Cedars

This inspection was carried out on 23rd May 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Welcome House - The Cedars 19/06/07

Welcome House - The Cedars 07/02/06

Welcome House - The Cedars 15/02/05

Welcome House - The Cedars 19/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Welcome House - The Cedars The Cedars 2 Hartlip Hill Hartlip Sittingbourne Kent ME9 7PA Lead Inspector Joseph Harris Unannounced Inspection 23rd May 2006 10:00 Welcome House - The Cedars DS0000024041.V300020.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 Welcome House - The Cedars DS0000024041.V300020.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. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Welcome House - The Cedars Address 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) The Cedars 2 Hartlip Hill Hartlip Sittingbourne Kent ME9 7PA 01795 843837 01795 842209 Dr Toqeer Aslam Ms Heidi Baum Dr Toqeer Aslam Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: The Cedars is a large detached property with accommodation on three floors, offering twenty single and three double rooms, which are all currently used as single rooms. There are three sitting rooms on the ground floor, one of which is a smoking room. There is also a large dining room and a domestic sized kitchen. The home is located on a busy arterial road between Rainham and Sittingbourne, with the village of Newington some 15-20 minutes walk away, where shops and a mainline railway station are situated. There is a bus stop 200 yards from the property, which offers an hourly service to Rainham and Sittingbourne. The home does not have dedicated transport. There are reasonably well-tended gardens to the front and rear of the building, and ample parking for cars. The current scale of charges at The Cedars is £540 per week. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was completed on 23rd May 2006 by Joe Harris (link inspector) and Mark Hemmings. The inspection started at 9.30 am and lasted for approximately 8 hours. During the course of the visit discussions were held with service users, staff, the deputy manager, the registered manager, the responsible individual and quality assurance manager. A tour of the premises was undertaken and a range of documents were viewed relating to service users, staff and health and safety amongst others. What the service does well: What has improved since the last inspection? The registered manager and staff team have made a number of improvements since the last inspection. This is particularly highlighted through the beginning of a comprehensive review of service user files. It is acknowledged that this is an on-going process, but positive steps have been taken to address previously highlighted shortfalls. The staff and service users have also made efforts to improve cleanliness in the home and the service appeared clean and hygienic at the time of the visit. In discussion with staff and through observation it was evident that the staff on duty had good levels of understanding about the needs of the individual service users and a knowledge of mental health issues in general. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 6 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. Welcome House - The Cedars DS0000024041.V300020.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 Welcome House - The Cedars DS0000024041.V300020.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): 1, 2, 4 and 5. Prospective service users are provided with generally adequate information about the home. The service user guide and statement of purpose have been reportedly updated, but these documents were not readily accessible in the home. Prospective service user’s needs and aspirations are assessed prior to admission. Prospective service users have the opportunity to visit the home before choosing whether to move in. Each service user is provided with a written contract. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service EVIDENCE: A service user’s guide and statement of purpose were accessible and available for all in one of the lounges. These documents covered, in reasonable detail, the aims and facilities of the home. It was reported by the responsible individual that these documents have been reviewed and updated to include more service specific information. These updated documents should be made available and the service user’s guide provided to all new and prospective service users. The current statement of purpose states that respite care is offered and clear information needs to be included to reflect this specific aspect of the service. Refer to recommendation 1. Service users are referred through Care Programme Approach and Care Management processes. The home requests information from referrers prior to admission including care plans, risk assessments and other background Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 9 information. All service user files viewed contained pre-admission assessment information. The home has also improved assessment processes and has developed new assessment forms, which have been completed to a good standard. The home liaises with care managers, other mental health professionals and families, where appropriate regarding needs, aspirations and any potential restrictions on freedom or choices. The registered manager confirmed that all prospective service users are invited to visit the home prior to choosing whether to move in. One prospective resident was visiting the home with his family on the day of the inspection. Overnight stays can be offered if desired. All new service users have a settling in period in the home following which a review of the placement is arranged with relevant individuals. An adequate contract covering the terms and conditions of the residency is provided to all service users. A copy is given to the service user and a signed copy is also retained on file. Welcome House - The Cedars DS0000024041.V300020.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, 8, 9 and 10. The home is in the process of updating all service user plans, which are being completed to an adequate standard. Service users are able to make decisions about their lives. Service users are able and encouraged to assist in the day-to-day running of the home. The home is in the process of updating risk management processes, which are being developed to an adequate standard. Information about service users is handled in a confidential manner. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A number of service users plans were examined during the course of the visit. The registered manager and senior staff are in the process of updating all the plans. New documentation has been introduced providing background information in the form of pen pictures, care plans and risk assessments. The updated plans have been completed to a good standard and provide clear guidance for staff to enable them to meet the needs of each individual service user. The files have also been reorganised to ensure that relevant and ‘live’ information is at the forefront with out of date information being archived. It is acknowledged that this process of updating will take time to be completed for Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 11 all service users, but should signify a positive step forward. The plans are reviewed every three months or when significant changes occur. Care plans are informed by CPA documentation, but address health care, social and daily living needs. It was noted that some attention should be given to the actions documented addressing skills training to ensure that outcomes can be measured. Where specific training is provided a clear and consistent process should be outlined to enable service users to work towards short and longterm goals. Refer to requirement 1 and recommendation 2. Service users confirmed that they are able to take decisions affecting their day-to-day lives with regard to routines, activities and finances stating that the staff are supportive and helpful. There is a notice board and other information available in the home regarding local resources and amenities. Information should also be made available regarding advocacy services and any self-help groups. Refer to recommendation 3. The majority of service users manage their own finances. The responsible individual is appointee for two service users, but adequate processes are in place to ensure accountable management of these finances. Service users are able to participate in the day-to-day running of the home dependent on needs and wishes. Regular resident meetings take place with recorded minutes, which are placed on the notice board. Some service users take a more active role in the home assisting in the kitchen and with cleaning and household chores. The registered manager is in the process of updating risk assessments and an improved risk management process has been introduced. A number of the risk assessments have been reviewed and this is on-going. The updated plans address risks in a more consistent manner, however attention needs to be paid to the actions to minimise the assessed risks ensuring clear guidance is in place. Refer to requirement 2. Risk assessments are reviewed at least every 3 months or in line with changing needs. All information is handled in a confidential manner. Staff are instructed about issues of confidentiality. There are also policies and procedures in place. All confidential written documents are stored securely. Welcome House - The Cedars DS0000024041.V300020.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 and 17. The home needs to investigate further opportunities for meaningful and leisure activities. Service users are able to access the local community, but transport issues need to be addressed. There are opportunities to maintain relationships with families and friends. Service user’s rights and responsibilities are respected. A reasonably healthy diet is provided with available choices. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was reported by the registered manager that there is a lack of resources in the local area specifically for people with mental health needs. As a result of this the majority of service users are not able to access community mental health or educational resources. Two service users are currently attending college courses. A discussion was held with the registered manager regarding this issue and it is advised that the home further investigates opportunities available in the nearby towns and considers providing a greater level of meaningful activities within the home as part of the comprehensive care plan reviews currently being undertaken. Refer to recommendation 4. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 13 The home is set in a relatively isolated location with poor public transport access, there is a minimal staff team on duty at all times and the home does not have access to any dedicated transport. These factors severely limit the ability of the majority of service users to become part of the local community. Many of the service users spoken to stated that the poor transport options are one of the major frustrations about living in the home. One service user stated that she can take the bus service to Rainham, but has to get a taxi back at considerable cost to herself. Another service user said that it can cost around £20 for her to visit her doctor if the one staff member with appropriate transport is not available to escort her. The home operates with a small staff presence on each shift, which also limits the flexibility to be able to support service users in the community. These issues were discussed with the registered manager and responsible individual and need to be positively addressed. Refer to requirement 3. The home has recently developed weekly activity planners and staff are working with service users to complete these. However, of the planners viewed the majority focussed on household chores and personal hygiene issues. There was little emphasis on leisure activities. There are leisure activities available in the home such as music and television, but a lack of organised activities are available either in or out of the home. One service user stated that although he likes living in the home it can get ‘a bit boring, there’s not much to do.’ Another resident said that they are ‘happy doing my own thing’ but went on to add that it is difficult to get to the local towns because of the poor bus service. The registered manager stated that the home does not offer an annual holiday, but a day trip out was being organised for the summer. No activities or entertainments are brought into the home, which should also be considered. Refer to requirement 4. There is a welcoming atmosphere in the home and the families and friends of service users are welcome to visit at reasonable times. Service users confirmed that their visitors are made welcome and there is adequate space in the home to enable people to meet in private should they wish to do so. The daily routines in the home are flexible and service users can exercise their individual choices and personal freedoms. Residents stated that staff are respectful and knock before entering their rooms and that they have good relationships with all members of the staff team. Many of the residents take part in household chores and other tasks on a day-to-day basis. There are also rules regarding smoking and alcohol on the premises. Menu records were examined and a 4-week rolling menu is in operation. Choices are available at each meal time and the menus demonstrate a balanced and healthy diet is offered. It was noted that there was a high proportion of frozen foods in stock, but no fresh vegetables and little fresh fruit at the time of the visit. One staff member stated that they were due to complete the weekly shopping and that this is not normally the case. A number of the service users stated that they quality of food is good and that choices are always available. The home does not have a dedicated cook and staff have to prepare all meals with some assistance from service users at times, which does have an impact on staff availability at these times of the day. The Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 14 registered manager confirmed that where special diets such as diabetic, vegetarian and cultural diets are required these are catered for. There is a good-sized dining room and meals are taken in a relaxed and unhurried atmosphere. Service users can also choose when and where to eat within reasonable boundaries. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Service users receive personal support in the way that they prefer. Healthcare needs are met. Medication storage requires some attention, but records and procedures are relatively well managed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of service users are largely self-caring requiring prompting with aspects of daily living skills. Where personal support is required staff provide this in private. Individual’s daily routines are flexible and people can choose what time they get up and go to bed, etc. The home is currently updating care plans, which will provide clearer guidance for assistance with personal hygiene needs where appropriate. The home could utilise additional specialist support to a greater degree, especially with regard to Occupational Therapy, but in general healthcare issues are referred appropriately to General Practitioners and Community Mental Health teams. There is a broad key worker system in place. The home is in the process of improving record keeping and monitoring with regard to healthcare issues. Service users are able to keep their own GPs and receive good support from local community mental health services. Health care needs are monitored and referred appropriately. Where service users visit healthcare professionals independently there are access and transport issues Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 16 and one service user also stated that she ‘would like more support from staff’ at times when attending appointments, but the availability of staff is not always feasible due to staffing levels. Additional healthcare needs are also monitored such as optician, dental and chiropody appointments. The registered manager has worked to improve a number of issues with regard to medication. There are policies and procedures in place relating to medication issues. Staff competency relating to medication is well monitored. All staff have completed the Boots MDS training and senior staff have undertaken the more advanced Protocol training. The registered manager has developed an in-house competency and training package, which addresses issues in good depth. Only one service user is currently self-medicating and although an assessment has been made for this individual’s competency, the assessment pro-forma needs to be reviewed including open-ended questions. Refer to recommendation 5. Medication records were generally well kept and up to date and records of returned and destroyed medication also kept. The home needs to address medication storage. The medication cupboard was somewhat disorganised and staff have to carry a large box of medication down two flights of stairs prior to administration. The medication cupboard is poorly lit, lacks ventilation and had a room temperature of 23C. Attention needs to be paid by the responsible individual to ensure that the storage facilities in the home meet the requirements as set out in the Royal Pharmaceutical Society of Great Britain guidance for care homes. Refer to requirement 5. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. There is an adequate complaints process in place. There are adequate processes in place to protect service users from forms of abuse. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear and accessible complaints procedure in place addressing all relevant topics. Service users stated that they would feel able to complain to the registered manager or staff on duty if they had an issue. Resident meetings are held regularly providing service users with the opportunity to raise issues of note. There are adequate policies and procedures in place addressing adult protection issues and abuse. There is a whistle blowing procedure in place. Staff demonstrated an awareness of these procedures and an understanding of adult protection protocols. Policies and procedures relating to financial matters are in place and records maintained. All staff have attended adult protection training. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28 and 30. The home is comfortable and safe. Bedrooms suit needs and lifestyles and promote independence. Toilets and bathrooms meet the needs of the service users. There is a sufficient range of communal space. The home is clean and hygienic. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The tour of the premises demonstrated that the home is presented to a normal domestic standard and it was reported by staff that no equipment or facilities were in need of or awaiting repair. It was also reported that the home meets the requirements of the fire safety and environmental health departments. However, the documentation relating to these issues was not available for inspection and is kept at the head office. It was advised that these documents should be available for inspection prior to the next visit. Several service users bedrooms were viewed all of which meet individual space requirements. All bedrooms are single occupancy and it was reported that there had been no changes to the layout of any rooms. A number of service users spoken to stated that they were happy with bedrooms and that they provided satisfactory space. All bedrooms viewed contained adequate furniture and fittings to meet the needs of the service users. It was noted that some Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 19 furniture had been subject to heavy wear and may benefit from renewal in the near future, however residents spoken to stated that they had all of the resources that they need in their bedrooms. There are sufficient numbers of toilets and bathrooms throughout the home, which appeared clean, albeit functional. Some consideration could be made by the registered manager to make these areas more homely. There is a reasonably good range of communal spaces on the ground floor of the home. There is a large non-smoking lounge, which, it was reported, is often used for meetings and visitors. There is another smaller television lounge and an additional smoking room. The home also has the benefit of a reasonably sized dining room, which is used for activities at other times of the day. There is adequate furniture and fittings in all of the communal spaces. It was reported that laundry facilities are adequate for the needs of the home, although this area was not viewed by the inspectors. Service users confirmed that their clothes are appropriately cleaned and presented. Staff spoken to were not aware if the appropriate water fittings had been installed by the water company and agreed to get further clarification from the registered provider in this regard. Refer to recommendation 6. In general the home appeared clean and hygienic and universal precautions are in place to control the spread of infection. The kitchen area also appeared clean and well-kept. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 20 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, 33, 34, 35 and 36. The home is working towards NVQ targets and staff demonstrated adequate levels of competency. Staffing levels in the home are minimal and are in the process of being reviewed. Recruitment practices are generally adequate, although some omissions in staffing records were identified. Staff receive adequate levels of training. Induction processes are to be further strengthened however, which is currently being reviewed by the responsible individual. Supervision systems are adequate. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two members of the current staff team have achieved NVQ level 2 with a further two members of staff working towards this qualification. The registered manager stated that the home is committed to achieving the target of a minimum of 50 of the staff team attaining relevant NVQ qualifications. Refer to recommendation 7. Through discussion and observation support workers demonstrated good levels of competency and an understanding of mental health needs and the specific needs of individual service users. Staff, independently, were able to outline methods of managing a number of scenarios in a consistent and competent manner. Service users confirmed that they feel supported by staff and have been able to develop positive relationships. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 21 Current and past duty rotas were examined demonstrating that two support workers are on duty throughout the day (8am-10pm) and one sleep-in member of staff is on duty at night, who has the benefit of an on-call back-up system. In addition to this a senior member of staff is also on duty throughout the weekdays between 9-5pm. The home has a small staff team, but it was reported that there have been no recent incidents when this level of staff compliment has not been able to be maintained. Recent service user’s daily records demonstrated that there had been no incidences of disturbance at night and staff stated that the on-call system provides adequate back-up. The registered manager stated that if a staff member is significantly disturbed at night efforts are made to ensure that they can leave early the following. The registered manager also stated that she will ensure extra staff are on duty in times of need. The home does not employ any ancillary staff such as domestics and kitchen staff, which places a further burden on the staff members on duty. One member of staff stated that if the number of service users were to increase then the home would “definitely require more staff”. Some concern was raised with the registered manager and responsible individual about the availability and flexibility of staff to support service users in the community during the day and, in terms of health and safety and fire safety, staffing numbers at night. A lengthy discussion was held regarding staffing levels and it was agreed that the home would continue with in-depth reviews of the needs of all service users and review staffing levels accordingly following this process. This area of concern will, therefore, be re-examined at the next inspection with regard to the outcomes for service users and health and safety issues. Refer to recommendation 8. A random sample of recruitment and staff personnel files were viewed, which demonstrated that appropriate recruitment practices and procedures are in place. It was noted, however, that some omissions were evident in the employment history of a number of staff. There was no evidence of further investigation by the home management in this regard prior to employment. This was discussed at length with the responsible individual and registered manager, who agreed to address this matter and to ensure that care-related references are obtained in all circumstances. Refer to recommendation 9. Training records were examined. All staff undergo a basic one-day induction session covering key elements, however it was agreed that this process should be further enhanced and strengthened. It was acknowledged by the registered manager and responsible individual that a more in-depth induction based on the Skills for Care Common Induction Standards should be introduced, which can be completed over a longer period to ensure that the home management can evidence competency levels. Refer to recommendation 10. All staff have completed the required training courses and additional in-house training is also provided to supplement these courses. Other training provided has included adult protection and mental health needs. Support workers also complete TOPSS based assessments. An adequate system of staff supervision is in place, with all staff spoken to confirming that they feel supported in their roles. There is a cascading system of supervision in place. Supervision records demonstrate the staff receive Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 22 regular 1:1 sessions with a senior member of staff and issues relating to care and performance are addressed. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The registered manager is experienced and appropriately qualified. Quality assurance systems are in place, however a system for evaluating feedback should be introduced. Health, safety and welfare issues are maintained, however a number of fire safety issues need to be addressed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for a number of years and has a good level of experience in home management and working with people who have mental health needs. She has completed her NVQ level 4/Registered Managers Award and has further management qualifications. The organisation has developed quality assurance systems and has recently appointed a Quality Assurance Manager. Staff reported that senior managers regularly visit the home and assess and reviews the needs and developments of the home. Regulation 26 reports were not viewed during this visit. Service user satisfaction questionnaires are completed, although it was not clear how frequently this exercise is undertaken. It was evident that no system had been Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 24 introduced for equating and evaluating these results in the form of an annual qualitative report. This was discussed with the management team who agreed to introduce this process by 1st January 2007. Refer to recommendation 11. Staff were observed to sensitively gain feedback from service users on an informal basis regarding daily routines and other daily issues. The majority of documents relating to health and safety issues were in place and up to date. There were a number of exceptions however, including the CORGI gas safety certificate, which had recently lapsed, but evidence was available to demonstrate that this assessment was due to be completed. Additionally the home needs to ensure that fire safety systems and instruction is kept up to date and maintained. A number of omissions were noted in this regard including checks on emergency lights and fire fighting equipment, the weekly checks of the fire alarm system and fire safety competency appraisals for staff. These issues were discussed with the home management and agreed to be addressed. Refer to requirement 6. Welcome House - The Cedars DS0000024041.V300020.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 2 2 3 3 X 4 3 5 3 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 3 25 3 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA6 YA9 Regulation 15(1) Requirement Timescale for action 01/09/06 01/09/06 3 YA13 4 YA14 5 YA20 6 YA42 To continue the process of updating all service user plans. 13(4) To continue to update all risk assessments ensuring clear actions are documented to minimise risks. 16(2)(m)(n) To ensure that service users have the option of flexible support and reasonable access to community resources. This includes access to transport and staff support. 16(2)(m)(n) To investigate and ensure a range of leisure activities are made available in and out of the home including regular organised activities and day trips. 13(2) To ensure medication storage facilities comply with the RPSGB guidelines for care homes. 23(4)(5) To ensure fire safety systems are adequately maintained and all checks are routinely carried out. 01/09/06 01/08/06 01/09/06 01/07/06 Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 27 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 5 6 7 8 9 10 11 Refer to Standard YA1 YA6 YA7 YA12 YA20 YA30 YA32 YA33 YA34 YA35 YA39 Good Practice Recommendations To ensure that updated copies of the statement of purpose and service user’s guide are available and include specific information about respite services. To provide clear guidance in service user plans addressing skills training. To provide accessible information regarding advocacy services and self-help groups. To investigate and inform service users of the range of meaningful therapeutic activities available in and out of the home. To review assessment process for self-medicating service users. To ensure that water fittings comply with relevant legislation. To continue to work towards NVQ targets. To complete comprehensive reviews of all service user’s needs and health and safety issues with regard to staffing levels. To ensure all gaps in employment history and care-related references are obtained. To update and strengthen the induction process in line with the Skill for Care Common Induction Standards. To introduce an annual quality report to evaluate feedback and service user satisfaction questionnaires. Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Welcome House - The Cedars DS0000024041.V300020.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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