Care Home: Cedar House

What the care home does well As previously identified most of the people living at Cedar House have lived together for some time and are very settled. Each are able to choose how they spend their time both in and away from the home. As always people living at the home make us welcome and are happy to speak with the inspectors. What has improved since the last inspection? We found that there had been no improvements made with regards to requirements made during our last Key and Random Inspections. What the care home could do better: Individual care plans still need to be developed with each resident detailing their support needs as well as providing clear direction for staff about how they wish to be supported ensuring their health and well being is maintained. Plans should be kept under review and reflect any changing needs. Risk assessments still need to be developed in all areas of concern and detail the support and intervention provided so that risks are minimised and people are kept safe. Effective arrangements need to be put in place for the safe handling of peoples medication. Record keeping needs to improve to better support and evidence the safe administration of medication as prescribed and risk assessments need to be completed to help ensure peoples medication needs are supported in the safest and best way when away from the home. Detailed monitoring records need to be implemented to so show that the health care needs of people are being addressed. These should also include all appointments, health care, routines and behaviour. This will enable the team to monitor any changes so that should additional support or intervention be required this can be done in a timely manner. More effective communication systems need to be introduced between the team so that everyone is aware of the current and changing needs of people in order to promote and proper arrangements for the health and well being of people. More meaningful consultation should be held with people about the opportunities made available to them so that they are able to take part in a variety of activities both within and away from the home, based on their individual needs and wishes. Suitable arrangements need to be put in place to ensure that sufficient food supplies are available at all times so that people are offered a choice and their nutritional needs are met. Relevant health care professional still need to be contacted so that proper arrangements can be made for peoples continence care ensuring their health and well being is maintained. All concerns brought to their attention of management must be recorded in full and detail the action taken, along with the outcome and personnel involved. This will demonstrate that concerns raised are taken seriously and people feel they are listened too. More effective systems should be put in place with regards to the recording and management of individual finances so that the systems are robust and clearly demonstrated that money is being managed safely. A refurbishment plan still needs to be developed detailing all areas of the home, which need to be improved along with timescales for completion so that people live in a comfortable, well maintained home. More suitable arrangements need to be made in the laundry to prevent infection and the spread of infection within the home. The Register Person is again reminded that only those staff that have been robustly recruited should be employed to work at the home ensuring they have the qualities and competencies needed so that people are kept safe. The Registered Person still needs to ensure that sufficient staffing are provided at all times ensuring there are sufficient number of duty to meet the health and well being of people providing flexible support. A programme of staff training and development still needs to be provided by someone trained and experienced to do so ensuring all staff have the knowledge and skills needed to support the specific needs of people living at the home, for which it is registered. The Registered Person needs to ensure that a suitable person is appointed who has the knowledge, skills and experience needed to manager the home on a day to day basis. The Registered Person has previously been asked to complete records to demonstrate when she visits the home as part of her monitoring visits. These must be completed on a monthly basis and copies should be provided to the Commission to demonstrate that the service is being conducted in the best interests of those who live there. The Registered Person still needs to ensure that she fulfills her responsibility as an employer, in that, staff working at the home are provided with adequate statements of wages earned and deductions taken from their wages. The Registered Person must ensure that the financial management of the service is conducted in such a manner that this does not compromise the service and the safety of those who live there. A fire drill needs to be undertaken ensuring all people at the home, particularly new staff, are aware of the procedure to follow should an incident arise ensuring people are kept safe. Evidence of up to date safety checks need to be provided with regards to the gas supply and electric circuits ensuring people living and working at the home are kept safe from harm. Key inspection report Care homes for adults (18-65 years) Name: Address: Cedar House 47 Smethurst Street Cedar House Middleton Manchester M24 2BA     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Lucy Burgess     Date: 0 5 0 5 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 35 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 35 Information about the care home Name of care home: Address: Cedar House 47 Smethurst Street Cedar House Middleton Manchester M24 2BA 01616553553 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Ann Merabi Name of registered manager (if applicable) Type of registration: Number of places registered: care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 16 The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home Cedar House is a care home providing personal care for 16 adults, who have been diagnosed with a mental disorder. Three places are registered for residents over the age of 65 years. The home provides 16 single bedrooms, a lounge, conservatory, dining room, communal toilets and bathing facilities. Care Homes for Adults (18-65 years) Page 4 of 35 Over 65 0 16 Brief description of the care home Cedar House is located at the end of a residential street, approximately two miles from the town centre of Middleton. A number of small local shops, post office and pubs are near by. The home has a car park for residents and visitors. A grassed area is provided to the rear of the house and small garden areas to the front. Fees charged by the home in May 2009 ranged from 328.00 to 380.00 pounds per week. The home makes charges over and above the weekly care and accommodation fees for items such as hairdressing, magazines and newspapers, toiletries, activities and clothing. Care Homes for Adults (18-65 years) Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was the key inspection for Cedar House, which included a site visit and took place over one day by an inspector and a pharmacy inspector, for a period of 9 hours. The service did not know that the inspectors were to visit. As part of the inspection process the manager was asked to complete an Annual Quality Assurance Assessment (AQAA). This was requested on the 12 February 2010 with a timescale for completion by the 13 March 2010. A reminder letter was sent on the 16 March 2010 with a further timescale of 23 March 2010. Again this was not provided. The owner had contacted us to request a few extra days, which had initially been agreed however this again was not complied with. At the time of carrying out the inspection this had still not been received. The Registered Person is reminded that this is a legal requirement and failure to comply may result in further action being taken. The purpose of this visit was to follow up on requirements made at the key inspection Care Homes for Adults (18-65 years) Page 6 of 35 in November 2009 and the Random inspection in February 2010. The Registered Person had been served with a Statutory Requirement Notice with regards to medication following the key inspection. However we found that arrangements for handling and administering peoples medicines continued to put people at risk of not having their medicines when needed. This meant that the requirements of the Statutory Requirement Notice served in January 2010 were not met, in that they remain in breach of Regulation 12 (1) (b) and regulation 13 (2). As part of our improvement strategy and on going enforcement work the Registered Person has been invited for interview under PACE (Police and Criminal Evidence Act) to explain why the issues had not been addressed. A further Statutory Requirement Notice was issued following the Random Inspection in relation to care plans. Compliance in this area was checked during this visit. Again no progress had been made. This meant that the requirements of the Statutory Requirement Notice served on the 14 April 2010 was not met, in that they remain in breach of Regulation 15 (1). We have also wrote to the owner and Registered Person on several occasions requesting further information be provided to us to evidence the viability of the home as well as confirming other areas of concern had been addressed. We have received no formal response to our requests. This does not demonstrate that the home is being conducted in a way, which ensure that safety and protection of those people who live their. Due to the on-going concerns the owner was advised that we would be holding another management review meeting to discuss what further action we need to consider as a result of our findings. This may result in further enforcement action being taken. During this visit time was spent looking at records including care files, staff recruitment, training and development, health and safety and management and conduct. A full audit of the medication system was also carried out. At present the Local Authority is not making placements at the home due to on-going concerns about the standard of care provided. The Local Authority convened a Commissioning Panel meeting, held on the 19 March 2010 to discuss the future of the home. Following the meeting the owner was advised that a decision would not be made for up to 3 months giving them opportunity to make the improvements needed. Due to the issues again found during this visit, copies of records were taken under a code B and will be used when consider what further action we need to take with the home. Feedback surveys were sent out prior to this visit. we received completed surveys from 3 people who live at the home and 6 staff. We also spent time during the visit speaking with residents, staff and the owner. Comments have been included in the report. Care Homes for Adults (18-65 years) Page 7 of 35 What the care home does well: What has improved since the last inspection? What they could do better: Individual care plans still need to be developed with each resident detailing their support needs as well as providing clear direction for staff about how they wish to be supported ensuring their health and well being is maintained. Plans should be kept under review and reflect any changing needs. Risk assessments still need to be developed in all areas of concern and detail the support and intervention provided so that risks are minimised and people are kept safe. Effective arrangements need to be put in place for the safe handling of peoples medication. Record keeping needs to improve to better support and evidence the safe administration of medication as prescribed and risk assessments need to be completed to help ensure peoples medication needs are supported in the safest and best way when away from the home. Detailed monitoring records need to be implemented to so show that the health care needs of people are being addressed. These should also include all appointments, health care, routines and behaviour. This will enable the team to monitor any changes so that should additional support or intervention be required this can be done in a timely manner. More effective communication systems need to be introduced between the team so that everyone is aware of the current and changing needs of people in order to promote and proper arrangements for the health and well being of people. More meaningful consultation should be held with people about the opportunities made available to them so that they are able to take part in a variety of activities both within and away from the home, based on their individual needs and wishes. Suitable arrangements need to be put in place to ensure that sufficient food supplies are available at all times so that people are offered a choice and their nutritional needs are met. Relevant health care professional still need to be contacted so that proper Care Homes for Adults (18-65 years) Page 8 of 35 arrangements can be made for peoples continence care ensuring their health and well being is maintained. All concerns brought to their attention of management must be recorded in full and detail the action taken, along with the outcome and personnel involved. This will demonstrate that concerns raised are taken seriously and people feel they are listened too. More effective systems should be put in place with regards to the recording and management of individual finances so that the systems are robust and clearly demonstrated that money is being managed safely. A refurbishment plan still needs to be developed detailing all areas of the home, which need to be improved along with timescales for completion so that people live in a comfortable, well maintained home. More suitable arrangements need to be made in the laundry to prevent infection and the spread of infection within the home. The Register Person is again reminded that only those staff that have been robustly recruited should be employed to work at the home ensuring they have the qualities and competencies needed so that people are kept safe. The Registered Person still needs to ensure that sufficient staffing are provided at all times ensuring there are sufficient number of duty to meet the health and well being of people providing flexible support. A programme of staff training and development still needs to be provided by someone trained and experienced to do so ensuring all staff have the knowledge and skills needed to support the specific needs of people living at the home, for which it is registered. The Registered Person needs to ensure that a suitable person is appointed who has the knowledge, skills and experience needed to manager the home on a day to day basis. The Registered Person has previously been asked to complete records to demonstrate when she visits the home as part of her monitoring visits. These must be completed on a monthly basis and copies should be provided to the Commission to demonstrate that the service is being conducted in the best interests of those who live there. The Registered Person still needs to ensure that she fulfills her responsibility as an employer, in that, staff working at the home are provided with adequate statements of wages earned and deductions taken from their wages. The Registered Person must ensure that the financial management of the service is conducted in such a manner that this does not compromise the service and the safety of those who live there. A fire drill needs to be undertaken ensuring all people at the home, particularly new staff, are aware of the procedure to follow should an incident arise ensuring people are kept safe. Care Homes for Adults (18-65 years) Page 9 of 35 Evidence of up to date safety checks need to be provided with regards to the gas supply and electric circuits ensuring people living and working at the home are kept safe from harm. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 10 of 35 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 11 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. At present no new placements are being made at the home until such time the standard of care provided has improved ensuring peoples needs are fully met. Evidence: Over the last year no new placements have been made at the home due to issues identified in relation to the standard of care provided. These have been considered by relevant parties. Due to this the Local Authority made the decision to suspend placements at the home until such time they were satisfied that people would receive a good standard of care and were kept safe. On the 19 March 2010 the Local Authority convened a Commissioning Meeting to discuss the continuation of funding placements at the home. The Registered Provider was given a period of 3 months to make the improvements needed. Due to this we have been unable to review the assessment process along with information gathered prior to people coming to live at the home. Care Homes for Adults (18-65 years) Page 12 of 35 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Without detailed information about how people are to be supported there is no assurance the health and well being of people will be met safely. Evidence: At our random inspection in February 2010 we found that new care plan documentation was being introduced and files reorganised so that only current information was available to staff. However on four of the files examined the current care plan had been archived and no new plan had been developed. This meant that there was no information available for staff about the current needs of residents and how they wish to be supported. Due to this we issued a Statutory Requirement Notice on the 14 April 2010 outlining the breaches in Regulation found in the four files examined. A compliance date was set for the 30 April 2010. During this visit we checked if compliance with this notice had been met. We again checked the 4 files specified in the notice. We found that no improvements had been made. We were shown a kardex record which had been completed by the deputy Care Homes for Adults (18-65 years) Page 13 of 35 Evidence: manager. Information provided a pen picture of each person identifying their support needs and areas of risk however this information had still not been transferred to the care plan or risk assessment forms, which remained blank. Previously we found that a night report book had been introduced by one member of staff however generally other staff did not use it therefore it stopped being used. Since our last visit a day diary had been introduced however this too had been completed over a three week period then ceased to be used. Monitoring sheets held on individual files were also examined. Again these still varied in relation to the level of information provided and frequency in which they were completed. These too were not kept up to date with no entries being made since March 2010. We again found that records provided no evidence of peoples routines, details of appointments along with evidence that any actions had been followed up or of any monitoring with regards to peoples changing needs or behaviours. It is very concerning that staff do not have accurate up to date information about how they are to support the needs of people. Furthermore the lack of evidence to show that the health and well being of people is being monitored does not ensure their safety. The lack of progress made is poor and does not demonstrate that the Provider is carrying on the service in a manner which ensure the needs of people living are being met safely. Care Homes for Adults (18-65 years) Page 14 of 35 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Opportunities for personal growth and development need to be improved so that people receive a service, which promotes their individual growth and development. Evidence: We have repeatedly identified that lack of opportunity provided to people to promote opportunities for social, recreational and educational growth. We were told by staff and residents that there had been a recent residents meeting. Activites were discussed as well as suggestions for the annual holiday. However no other opportunities have been provided. This was confirmed by people spoken with on the day. In the main the residents spend a lot of time in the home relaxing with each other. We asked the whereabouts of two people we had not seen during the day. One person was said to have gone to bed, and does so for a number of days. Whilst staff were Care Homes for Adults (18-65 years) Page 15 of 35 Evidence: unsure if the second person had returned to the home and thought they may be in their room. We again found that some staff had little interaction with people and spent time doing tasks away from residents or where sat chatting together and smoking. Later in the afternoon one member of staff did go for a walk with three of the residents. Staffing arrangements still do not allow for any flexibility in support or afford people a quality service. Meal arrangements were again looked at. The weekly shopping is done by the owner. The cook explained that she was unhappy with the current arrangements as on occassion they had run out of food items and were sometimes having to make do or items requested were not being bought. It was unclear what consultation was being made with residents about what they would prefer. We looked at the stock availbale, there were frozen vegetables and meat availbale however there was little dried, tinned or fresh items available. The cook and a staff member said that they had suggested the cook carry out the weekly shop, however nothing had been agreed. A number of comments were recieved from people on the surveys. They said, good choice of meals, they need to arrange more activities in house the meals are lovely, we have a holiday every year and need some more activities. Care Homes for Adults (18-65 years) Page 16 of 35 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements to ensure the health and well being of people are inadequate. The management of medication remains poor and does not ensure people receive their prescribed medication safely. Evidence: We identified during our last visit that the health care needs of one person had not been followed up. We looked at this again and found that no progress had been made. Arrangements should be made for a referral to the continence advisor so that suitable provisions can be made available. Records for another resident showed that the person had been seen by the GP in March. The outcome of the visit was that further tests were needed. However there were no further entries on the records to show that these had been acted upon. A third file showed that the person had become quite anxious and on occasions self harmed, whilst they had seen a health care professional, there was no further monitoring of this person. As stated earlier in the report daily records are not routinely completed and therefore the lack of monitoring in relation to the health care needs of people does not demonstrate that people are being supported in a way which ensures Care Homes for Adults (18-65 years) Page 17 of 35 Evidence: their health and wellbeing is maintained. Feedback was received from people in the feedback surveys about the care they receive. They said, they keep me safe, treat me with respect and care and they care about me and look after me very well. Serious concerns about the safe handling of medicines were identified at our previous visits. A Statutory Requirement Notice was issued to the registered manager and registered provider of the home in January 2010. This notice required the manager and owners operating the home to improve the control of medicines. At this visit we found weaknesses in the arrangements for handling and administering peoples medicines continued to put peoples health and well-being at risk. This meant that the requirements of the Statutory Requirement Notice served in January 2010 were not met, in that they remain in breach of Regulation 12 (1) (b) and Regulation 13 (2). We looked at how medicines were recorded and found omissions (gaps) in recent records for the receipt, administration and disposal of medicines that meant it was not always possible to account for (track) the safe handling of medicines in the home. It was of concern that on two days records were not completed to show the administration of anyones lunchtime or teatime medicines. This poor record keeping did not support and evidence the safe administration of medication at the home. Because of the poor record keeping, although the monitored dosage system was used correctly, it was not always possible to tell whether medicines in traditional boxes and bottles had been given as prescribed. On occasion records impossibly showed that more doses had been given than had actually gone from stock. We were concerned to see that records showed instructions for reducing the dose of one persons medication had not been followed correctly. We saw that someone else had no stock of painkillers on the visit day. Staff said that only a limited supply was prescribed each month. In this case information about their use should be included within their care plan to help ensure they are available when needed. We looked to see how information within peoples care plans supported the safe handling of medication. We were concerned to find that although medicines were now supplied for administration away from the home, when needed. Risk assessments had not been completed for everyone who managed their own medicines and there was no written information about how the medicines were supplied. It is important that written assessment are completed to ensure that if medicines are needed when people are away from the home, they are supplied in the best and safest way. There was no evidence that health care professional advice had been sought to see whether for example, doses could be given at different times, rather than taken away from the Care Homes for Adults (18-65 years) Page 18 of 35 Evidence: home. We found some individual information about the use of when required medicines but this could be usefully expanded to help ensure consistency in their use, when needed. Since our previous the previous manager had observed staff administering medicines but there were no regular audits of medicines handing and competency assessments had not been carried out to help ensure that staff understand and follow the homes procedures for handling medicines. Care Homes for Adults (18-65 years) Page 19 of 35 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Record in relation to complaints and finances need to accurately reflect what has taken place so that peoples interests are protected ensuring their safety. Evidence: People living at the home are aware of the complaints procedure and know who to speak with if they have any issues or concerns. We identified during our previous visits that a number of residents had raised concerns about a member of staff. The investigation into this matter had not been concluded and the manager was asked to address this at our last visit. Information seen this time showed that training had been identified for staff, however no action had been taken to provided it. This should be addressed. The owner advised us that a further complaint has been raised by one of the resident. This was being explored however there was no evidence of this. The owner was advised that records need to show what action is being taken along with the outcome so that this demonstrates that issues raised are taken seriously and people feel they are being listened to. We were advised that staff had previously attended training in safeguarding however again no certificates could be provided. New staff have yet to complete the course. Care Homes for Adults (18-65 years) Page 20 of 35 Evidence: We again looked at records in relation to people finances. Whilst these had improved the owner needs to ensure that records are kept up to date and each transaction clearly shows people finances are being managed safely. Care Homes for Adults (18-65 years) Page 21 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. More investment needs to be made to the environment so the people are provided with a good standard of accommodation which is comfortable and safe for them to live in. Evidence: Since our last Key Inspection there have been no improvements made to the environment. The owner was spoken with during the visit. We were told that they intended to start decorating the home the week following our visit. Due to a number of bedrooms being vacant, people would be asked to move around so the rooms can be painted. The owner also said that that he would ask a member of staff to compile a list detailing what work is required. This should be developed into a refurbishment plan and details dates for completion so that we can monitor progress in this area. One room previously identified which required new flooring had still not been addressed. We had been told that a flooring contractor was visiting the home in February to advise on suitable flooring, however nothing further has been done and remains in a poor condition. This must be addressed. Issues have previously been found with regards to the laundry. The washing machine Care Homes for Adults (18-65 years) Page 22 of 35 Evidence: has again broken down on at least two occasions since our last visit. This was concerning as we are aware that some people are supported with continence care. Adequate arrangements must be made so that this does not reoccur and items are laundered promptly to minimise any health and safety issues. Domestic tasks continue to be undertaken by a designated staff member each morning. One person commented on the feedback survey, saying, they keep the place more clean and tidy. As identified during our previous visit, satisfactory arrangements for a designated smoking area must be made as this continues to be within the dining room. Care Homes for Adults (18-65 years) Page 23 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Without robust recruitment along with quality staff training and development there is no assurance people will be supported by staff that are able to meet their needs safely. Evidence: Arrangements in relation to staffing levels were reviewed again. We recommended following our last visit that staff levels were kept under review to ensure that sufficient staff were on duty at all times. On examination of the rotas for 6 weeks prior to this visit we found that on some day insufficient staff were rotad or minimal staffing were available. This does not ensure that staff are readily available to meet the needs of people nor does it provide any flexibility in support. We also looked at recruitment. We were advised by the owner that since our last visit one new member of staff had been employed and a regular agency working was booked for shifts. However when speaking with staff we were advised that the agency staff had been taken on as an employee of Cedar House. We raised this with the owner who was unaware of this and assumed that the deputy manager had appointed the staff member. Recruitment information was requested for the two staff members. On the first file we Care Homes for Adults (18-65 years) Page 24 of 35 Evidence: found two application forms, interview checklist and an Independent Safeguarding Authority check (ISA), previously known as POVA check. We did not see however 2 written references. The interview checklist also showed that the application was not aware of the needs of this client group and what would be expected. We were advised by the owner that the deputy manager was shadowing this worker as their CRB check had yet to be received. However on inspection of the rotas we found that some of the more inexperienced staff had been rotad to work with the new worker. We were also advised by staff that at times these arrangements were not always effective. For the second member of staff documentation was been faxed through from the agency during our visit as the owner said he was unable to find the original documents. This information included 2 written references, an old CRB check (from a previous employer) and a recent ISA check. There were no other employment details. As this staff member is now said to be an employee of Cedar House, there was no evidence of them completing their own robust recruitment checks. This is poor practice. A statutory requirement notice was service in July of 2009 due to poor recruitment practices. Whilst this was met during a later visit, ongoing robust and safe practice has not been continued. This does not demonstrate that people living at the home are being protected. Progress in relation to staff training was also explored. Again no improvements were noted. Previously we had been told that staff had attended training in first aid, medication safeguarding and that they were waiting for certificates to be issued to evidence this. These were still not available. The home had made contact with the Local Authority with regards to the training they provide, dates were identified for April however there was no evidence that the courses had been attended. No further dates had been booked. We also discussed with the owner the quality of training previously sourced. Staff must receive good quality training relevant to their role and the people they support by facilitators that are skilled and experienced in those areas. There was also no evidence that new staff had received a comprehensive induction. This is concerning as we continue to find staff with little or no experience of working with people with mental health needs. Care Homes for Adults (18-65 years) Page 25 of 35 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of progress in relation to improvements needed does not demonstrate that the home is being managed and conducted in a way which ensures the interests of people are protected. Evidence: It was apparent at our previous visit that the working relationship between the registered manager and owner had broken down and was affecting the day to day running of the home. Since our visit the owner had advised us that the manager was no longer employed at the home. At present the home is being managed by the deputy manager with support from the owner. Current arrangements are inadequate as no progress has been made to address the improvements required. The owner advised us that arrangements were being made to recruit a new manager however no one person had been identified at that time. Further concerns still remain in relation to the viability of the home. Correspondence Care Homes for Adults (18-65 years) Page 26 of 35 Evidence: has been sent to the Registered Provider about this however no response has been made. Further requests for information from the Provider and owner confirming payment of bills and copies of regulation 26 reports have been made. Whilst we have received 1 regulation 26 report we have not received any further responses. The Annual Quality Assurance Assessment was also sent to the home on the 2 February 2010. The timescale for response was not met, a reminder was sent and again not responded to. The completed AQAA had still not received at the time of carrying out this visit. Again this is poor. The owner had previously advised that arrangements were being made for staff wages to paid through a BACS system arranged through a local company from April 2010. This would show what contributions would be made by each employee. Both the owner and staff confirmed that these arrangements have still not commenced. Again considering the lack of accounts available and improper financial management of the service as well as the failure to respond to our requests does not demonstrate that the service is being conducted in a way to safeguard the future of people at the home. A random check was made with regards to health and safety and servicing certificates. We found that the annual gas safety check and 5yr electric check was needed. The owners needs refer to the fire risk assessment carried out in November 2009 and ensure all action identified has been addressed. Furthermore a fire drill also needs to be undertaken ensuring all new staff are aware of the procedure to follows should an incident arise. Care Homes for Adults (18-65 years) Page 27 of 35 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 6 15 The registered person must 30/01/2010 ensure that care plans are kept under review and updated when necessary to show the current and changing needs of people so that staff are clear about the support to be provided. 2 9 12 The registered person must ensure that risk assessment are reviewed and updated ensuring that information reflects the current support needs of people. 30/01/2010 3 11 16 More meaningful consultation 30/04/2010 must be held with people about the opportunities made available to them so that they are able to take part in a variety of activities both within and away from the home, based on their individual needs and wishes. 4 19 12 The manager must liaise with 30/03/2010 relevant health care professional so that proper arrangements can be made for peoples continence care ensuring their health and Care Homes for Adults (18-65 years) Page 28 of 35 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action well being is maintained. 5 19 12 Records must be developed 30/04/2010 in relation to recording peoples health care, routines and behaviour. This will enable the team to monitor any changes so that should additional support or intervention be required this can be done so in a timely manner. 6 20 12 Consideration must be given 23/03/2010 to peoples medication needs when away from the home to ensure that as far as possible arrangements are made for medicines to be taken safely as prescribed at the best and right times. 7 20 13 The registered person must 24/01/2010 ensure that adequate stocks of medication are maintained without overstocking to enable continuity of treatment. 8 23 16 More effective systems must 30/03/2010 be put in place with regards to the recording and management of individual finances so that the systems are robust and clearly demonstrated that money is being managed safely. 9 30 13 More suitable arrangements 30/03/2010 Page 29 of 35 Care Homes for Adults (18-65 years) Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action must be made in the laundry to prevent infection and the spread of infection within the home. 10 33 18 Sufficient staffing must be provided at all times ensuring there are sufficient number of duty to meet the health and well being of people providing flexible support. 11 34 19 The register provider must 05/03/2010 ensure that anyone working, managing or carrying on at the home is robustly recruited and that all relevant information and checks are completed and available for inspection. This is to ensure that only those people fit to do so work at the home so that people are kept safe. 12 35 18 The registered person must 30/01/2010 ensure that the staff team receive training specific to the role and responsibilities to ensure their continued professional development as well as being able to meet the needs of service users in a safe way. This should be detailed in a training plan and should courses in medication, mental health awareness, care planning, substance misuse, health and safety, infection control 30/03/2010 Care Homes for Adults (18-65 years) Page 30 of 35 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action etc 13 39 26 The Provider must carryout 30/01/2010 the monthly monitoring visits in line with regulation and record her findings to show that the service is being monitored as part of a thorough quality reviewing process. Copies of the reports should be forwarded to the CQC. 14 43 25 The registered provider must 30/03/2010 ensure that the financial management of the service is conducted in such a manner that this does not compromise the service and the safety of those who live there. Care Homes for Adults (18-65 years) Page 31 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 Put into place an effective 07/06/2010 system to monitor the safety of medication practices to help ensure peoples health and well-being is best protected. 2 20 13 The registered person must ensure that complete, clear and accurate records of medicines received, administered and leaving the home are maintained to support and evidence the safe handling of medication. 07/06/2010 3 22 22 All concerns brought to their 30/06/2010 attention of management must be recorded in full and detail the action taken, along with the outcome and personnel involved. This will demonstrate that concerns raised are taken seriously and people feel they are listened too. Care Homes for Adults (18-65 years) Page 32 of 35 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 42 23 The registered person must provide evidence that an up date 5 year electric circuits check has been completed so that people are not place at risk. 30/05/2010 5 42 23 The registered person must ensure that any action identified on the fire risk assessment has been addressed so that people living and working at the home are kept safe. 30/05/2010 6 42 23 The registered person must provide evidence that an up date gas safety check has been completed so that people are not at risk of harm. 30/05/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 17 The registered person must ensure that adequate arrangements are in place with regards to food stocks so that people are offered choice and their nutritional needs are met. A refurbishment plan still needs to be developed detailing all areas of the home, which need to be improved along with timescales for completion so that people live in a comfortable, well maintained home. 2 24 Care Homes for Adults (18-65 years) Page 33 of 35 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 3 42 A fire drill also needs to be undertaken ensuring all new staff are aware of the procedure to follows should an incident arise. Care Homes for Adults (18-65 years) Page 34 of 35 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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