Inspection on 08/09/09 for The Cedars

This is the latest available inspection report for this service, carried out on 8th September 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Cedars 06/11/07

The Cedars 22/01/07

The Cedars 29/11/05

The Cedars 28/07/05

The Cedars 21/02/05

The Cedars 23/08/04

The Cedars 18/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Cedars High Street Purton Wiltshire SN5 9AF Lead Inspector Alison Duffy Unannounced Inspection 09:40 8 September 2009 th DS0000028140.V377887.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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 older people 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. The Cedars DS0000028140.V377887.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Cedars DS0000028140.V377887.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars Address High Street Purton Wiltshire SN5 9AF 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) 01793 772036 01793 772635 manager.thecedars@osjctwilts.co.uk www.osjct.co.uk The Orders Of St John Care Trust Mrs Michelle Lisa McKeever Care Home 49 Category(ies) of Dementia (12), Mental disorder, excluding registration, with number learning disability or dementia (4), Old age, not of places falling within any other category (42) The Cedars DS0000028140.V377887.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia- Code MDmaximum of 4 places Dementia- Code DE- maximum of 12 places Old age, not falling within any other category- Code OP- maximum of 42 places The maximum number of service users who can be accommodated is 49. 15th September 2009 2. Date of last inspection Brief Description of the Service: The Cedars was built in the 1980s as a purpose built residential care home. Originally managed by Wiltshire County Council, the home is now registered to the Orders of St John Care Trust. Mrs Michelle McKeever is the registered manager. The Cedars is situated in the village of Purton and is in close proximity to the various amenities. Peoples bedrooms, which offer single occupancy, are located on the ground and first floors. A passenger lift is in situ. There is a large dining room and adjoining lounge. Additional seating areas have been created within the main entrance and within some areas of the corridors. Staffing levels are maintained at six or seven care staff during the day. In addition there is a head of care. At night there are three waking night staff. There are also housekeepers, catering staff, an activities organiser, a maintenance person and an administrator. Designated staff work in the home’s integral day centre. Fees for living in the home are based on dependency levels and the type of room occupied. The fees range from £407.85 to £550.00. There is an additional supplement for premier en-suite rooms. Items such as chiropody, hairdressing, The Cedars DS0000028140.V377887.R01.S.doc Version 5.2 Page 5 dry cleaning and personal items are not included in the fee. The Cedars DS0000028140.V377887.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Before visiting The Cedars, we sent the home an Annual Quality Assurance Assessment (AQAA) to complete. The AQAA is the home’s own assessment of how they are performing. The AQAA tells us about what has happened during the last year and about the home’s plans for the future. The AQAA was returned on time and was comprehensively completed. We sent surveys, for people to complete if they wanted to. We also sent the home surveys to be distributed to staff and health/social care professionals. This enabled us to get people’s views about their experiences of the home. We received surveys from three people using the service, four members of staff and three health/social care professionals. We looked at all the information that we have received about the home since the last inspection. This helped us to decide what we should focus on during an unannounced visit to the home. This visit took place on the 8th September 2009 and the 10th September 2009. Mrs McKeever and Ms Debra Yeates, locality manager were available throughout and received feedback at the end. Mr David Jones, our Pharmacist Inspector visited the home on the 23rd September 2009, over a five hour period, to look at the arrangements for the handling of medicines. The visit was arranged due to the high level of medication errors, which had been made since the last inspection. Mr Jones looked at some stocks and storage arrangements for medicines and various records about medication. He saw how staff administered some medicines to people living in the home and spoke to the manager and two care staff who were on duty. Mr Jones gave feedback to the manager during the inspection about the medication issues found. Mr Jones’ findings are included within this report. During our visit, we toured the accommodation and met with people in their own bedrooms and communal areas. We spoke to staff members on duty and observed the serving of lunch. We looked at care-planning information, staff training records and recruitment documentation. We also looked at documentation in relation to health and safety and complaints. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people using the service. The Cedars DS0000028140.V377887.R01.S.doc Version 5.2 Page 7 What the service does well: There is a clear assessment process, which ensures people’s needs will be met within the home. People are encouraged to follow their own routines and make choices in their everyday lives. People’s rights to privacy and dignity are maintained. People have good access to healthcare services ensuring their health care needs are met. The environment is of a good standard and well maintained. Training is given priority and ranges of subjects, other than those, which are mandatory, have been arranged. Robust recruitment procedures are in place and a high level of health and safety material is available for staff reference. What has improved since the last inspection? Staff interactions with people were much improved. Staff spent time with people and communicated in a polite, respectful manner. The standard of care planning had improved. Care plans were more detailed enabling staff to have clearer information when supporting people. Staff had spent time with people, developing the individual’s life history in a clear, easy to read format. The dining room, lounge and corridor had been redecorated. Some bedrooms had new furniture. The laundry had been fully refurbished. There was greater staff presence in all areas of the home and therefore call bells were being answered without delay. A Head Housekeeper had been appointed. Accidents were being monitored and the level of falls had been reduced. Staff were recording better detail within the accident records. The Cedars DS0000028140.V377887.R01.S.doc Version 5.2 Page 8 What they could do better: 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. The Cedars DS0000028140.V377887.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before being offered a service, so are assured that their needs will be met. EVIDENCE: Within the AQAA, we saw that a robust assessment process was followed before the home was considered suitable for the person. The AQAA stated ‘all prospective residents are assessed prior to admission by a staff member who is trained and qualified and is able to ensure that we are able to meet the needs of the individual. Wherever possible, prospective residents visit the home. As this is not always possible, we endeavour to find alternative means to reassure them. For example, we have a selection of photographs in an album to help give a visual perspective and help them to make a more informed choice about moving in to our care home.’ The AQAA continued to state ‘we also consider the dependency levels of the existing resident group at The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 11 the time of the assessment and are able to make an informed decision as to whether the placement would be appropriate. Information is gathered from many sources, including the individual, family members, social workers and GPs.’ We looked at the assessment documentation of two new people to the service. The assessment was in a tick style format which generally required a ‘yes’ or ‘no’ answer to the questions asked. We saw that additional information had been recorded to give further clarity. The assessments showed people’s assessed needs and the support they required. There was information about people’s past medical history and the dates of their last optician, chiropody and dentistry appointments. We saw that confirmation had been gained from the person’s GP about the medication they were taking. There were assessments in place regarding the person’s risk of developing a pressure sore and their risk of falling. People also had a nutritional assessment in place. We saw that information from the assessment process had been used when developing the person’s care plan. We talked to two people about their admission to the home. One person said ‘my family made all arrangements for me.’ Another said ‘being local, you get to know the places that are good and bad. I thought things through for a while but decided upon this, as it was easy for people to visit me.’ Within surveys, health care professionals told us that the home’s assessment process ‘usually’ ensured that accurate information was gathered and that the right service was planned for people. Within their surveys, people said that they received sufficient information about the home before moving in. Staff told us that they now have a book of photographs of the home, which is taken to show people who are considering using the service. This enables people to visually see the home rather than trying to ‘picture it in their minds’. The Cedars does not provide intermediate care, so standard 6 is not applicable to this service. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning has been improved upon which ensures staff have the information to meet people’s needs more effectively. People have good access to health care provision. Peoples rights to privacy, dignity and respect are promoted. The inspection showed there were generally suitable arrangements in place for managing medication but continued attention is needed to make sure that actions already taken do in fact reduce the risk and numbers of errors when administering medicines and to review if any further changes are needed. EVIDENCE: People told us that they were very happy with the care they received. One person told us ‘I’m very content here. It couldn’t be better.’ Another person said ‘they look after us well. I don’t need to worry, as everything is taken care of. It gives me peace of mind.’ The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 13 Within surveys, people told us they ‘usually’ received the care and support they needed. Specific comments were ‘I get everything I need here. They are all very good,’ ‘we’ve had a lot of new staff but they’ve settled well and are all very likeable. They are very caring and work hard.’ In relation to what the home could do better, one person with the support of their relative told us, ‘bathing or showering more often especially with residents that have incontinence problems. Changing of bedlinen for residents with incontinence problems.’ We spoke to Mrs McKeever and a staff member about this. They said that people could have a bath when they wanted or needed one. They said that bedlinen would always be changed as required. While acknowledging this, we said that both aspects should be monitored to ensure that all staff follow this practice. At the last inspection, we made a requirement that all care plans must be fully completed and in sufficient detail to enable staff to have the required information to meet people’s needs effectively. Mrs McKeever told us that staff had worked hard to improve the standard of all care plans. Each plan had been reviewed and updated and greater detail had been added. Staff told us about the work they had undertaken. They said the plans were clearer and easier to use. We looked at four care plans in detail. We saw that there had been an improvement in making the care plans more person centred. One person had photographs and detailed information about their earlier life at the start of their plan. The detail within the documentation had also improved greatly. People’s basic care needs and additional information such as the prescription of antibiotics or the management of a sore area of skin, were clearly stated. As good practice, we saw that body maps had been used to show where any topical cream was to be applied. There was detail about people’s preferred routines and whether they preferred a male or female carer to support them with their intimate personal care. One person had a clear care plan about communication and how certain circumstances linked to self harm. Within care plans, there remained some information, which we said would benefit from further clarity. This included ‘try to encourage a well balanced diet,’ as it was not clear what this meant in practice. The plan continued to state ‘record all intake on food and fluid chart. GP aware of current condition.’ We suggested adding information about other factors such as the person’s nutritional likes and dislikes, the required consistency of their food and how they were to be supported with eating. The plan identified that the person needed to be checked ‘regularly’ through the day and night. We advised that specific timescales be stipulated to ensure staff were clearly aware of what support the person needed. There was good information about how the person was to be supported with their mobility. This included communicating with the person and moving them with as little discomfort and distress as possible. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 14 Some care plans contained some duplication. For example, one person had a plan of care regarding a specialised bed yet this had also been addressed within the prevention of pressure sores care plan. We saw that there was a care plan about resting and another for sleeping. Both contained similar information. Another person had a care plan for pain relief and another for pain relief patches. Mrs McKeever told us that she was aware of the duplication. She said it would be addressed when the care plans were next reviewed. We also advised that when care plans were evaluated, staff should assess whether the stated intervention remained accurate and appropriate. We saw within one care plan that the hoist had potentially caused some redness to a person’s skin. This had not been addressed when the mobility care plan had been reviewed. On the first day of our visit, we saw that one person had care charts in their room. These were to show the person’s food and fluid intake. There was also a chart to show when the person had been supported to change their position, to minimise the risk of pressure damage. The food and fluid charts had not been consistently completed. They had not been evaluated at the end of the day. Many showed insufficient fluid intake. Staff told us that they assisted the person to have a drink at key times and when they were in the person’s vicinity. They said this was on a regular basis. The charts did not reflect this. On the second day of our inspection, Mrs McKeever had developed new guidance for staff to follow. The guidance showed the person’s required fluid intake to maintain their wellbeing in relation to their weight. Mrs McKeever told us that this area would be monitored. People had their risk of developing a pressure sore assessed. Care plans gave information about how staff should support people to minimise the risk. This included specialised mattresses and cushions, the use of heel protectors at night and ensuring bedding and clothing were wrinkle free. We saw that one person needed support to change their position during the day and night. The ‘turning’ chart in the person’s room did not show that the person had been supported at the times identified in their care plan. We said that staff must ensure this is undertaken to minimise the risk of pressure damage. People had their risk of falling and malnutrition assessed. Manual handling assessments also formed part of the person’s care plan. These assessments had been regularly reviewed and updated. Within one person’s daily records, terminology such as ‘had full care’ was stated. We advised that the term should either be clarified or be expanded upon with the person’s care plan. We said that the care of the person’s teeth and nails should be included. There was also some subjective language such as ‘very uncooperative this am,’ ‘assisted to bed no problems’ and ‘very aggressive to staff.’ Mrs McKeever told us that this would be identified as a training issue and would be addressed with staff. As good practice, we saw that daily records demonstrated details of ill health and information such as The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 15 when a person’s pain relieving patch was changed. A clear record of any health care appointments and intervention, were maintained. Mrs McKeever told us that she had recently arranged free hearing tests for people. Within surveys, health/social care professionals told us that people’s social and health care needs were ‘always’ properly monitored, reviewed and met by the care service. In relation to what the home does well, one health/social care professional said ‘good continuity of care. Prepared to keep clients who need more than just residential care.’ Other comments were [do well] ‘individual needs and catering,’ ‘very approachable. The staff and manager coped with the resident very well despite many difficulties’ and ‘always helful and willing to discuss.’ In relation to what the home could do better, one health/social care professional said ‘inform us as nurses of clients deterioration so ‘end of life’ care can be supported and put in place.’ Another health/social care professional said ‘sometimes request visits for trivia and for clients who could get to the surgery. Some staff have unrealistic expectations of clients condition.’ At the last inspection, there were interactions between staff and people using the service, which did not promote people’s dignity. We made a requirement for measures to be taken to ensure that people’s privacy, dignity and wellbeing were not compromised by the practices of staff. Within this inspection, interactions were much improved. Staff responded to people well and were attentive and friendly. They spoke to people on arrival for their shift and regularly there after. People appeared genuinely pleased to see the staff and showed that good relationships had been built. We saw that staff knocked on people’s doors and waited to be asked in before entering. People were supported with their personal care in private. Within surveys, health care professionals told us that the service respected people’s privacy and dignity. Mrs McKeever had taken action to meet the statutory requirements relating to medication included in the report following the last key inspection in September 2008. The good practice recommendations we made had also been taken into account. The home have notified us of eight errors with medicines since March 2009 (including two a few days before and one just after the medication inspection). Mrs McKeever told us about actions taken and changes put in place as a result of investigations, into the reasons for these. For example, we saw that two medicine trolleys were used, two staff administered medicines and additional checks were made when all medication had been administered. The manager has in place regular audit checks of the arrangements for managing medicines. These sorts of checks help the home to be aware when errors have happened and perhaps the reason why, so that systems can be changed for the better. We will be monitoring to see that these measures are effective in reducing The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 16 errors. It is essential that arrangements for medication are safe and do in fact reduce the risk and occurrence of errors to an absolute minimum. In view of the number of errors, the manager must look critically at the medicine policy and procedures to be sure that staff do understand this and are following this properly; also to see if any changes are necessary to promote safer systems and if the appropriate checks and audits are made at the right time. The manager needs to consider other questions such as is the staff medication training and assessment of competence sufficient and suitable? Are all staff actually competent with handling medicines? Are there too many distractions for staff when administering medicines? Are there always enough staff on duty? Staff who administer medication first undergo training. The home also has a system in place to check the competence of the staff who administer medicines and we saw some training records. We spoke to one care leader who had good knowledge of various people’s needs and medication. Some staff measure blood glucose levels for some people and one member of staff said they had training from the district nurse for this. As this is a clinical task that the district nurse delegates to care staff, there needs to be records of training and delegation kept. Staff supported a few people living in the home to take responsibility for their own medication, to various extents, where a risk assessment showed this was safe. We spoke to one person who looked after his or her medicines and they told us all about the arrangements that were in place. Most people in the home relied on staff to deal with their medication for them. We saw that staff administered medicines on time and at the right intervals. They followed safe practices that also respected people’s privacy and choice. We spoke to Mrs McKeever about any cultural or equality and diversity issues that could affect medication for people living in this home and she told us that there were not any at present. There were arrangements for keeping records about medication received, administered and leaving the home or disposed of (as no longer needed) for each person living in the home. Accurate, clear and complete records about medication are very important in a care home where during any week a number of different staff will be involved with administering medicines. This is so that people are not at risk from mistakes with their medicines and that there is a full account of the medicines the home is responsible for on behalf of the people living there. The home has changed to a different pharmacy since the last inspection so there were slightly different systems and records in place. The records we looked at appeared to be in order. We did point out to the manager that records for an antibiotic course showed more doses were recorded as given than had been received. This may indicate the wrong dose was measured sometimes. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 17 There were specific plans where needed for each person about using any prescribed skin treatments together with records when staff applied these. We looked at some individual care plans to see what was written to give staff more guidance where more complicated treatment with medication was in use. We saw an example of good practice where a plan included information about avoiding grapefruit because of a particular medicine. For one person their plan for the management of pain needed updating as it did not include information about all the medication in use. Another care plan needed more specific information about using three prescribed laxative medicines. We looked at another care plan and records for managing diabetes and saw this included a lot of information but needed to include information about desirable blood glucose levels. A carer we spoke to told us about this but this sort of information needs to be accessible to all staff. There were suitable arrangements in place for managing warfarin treatment. It would be clearer, where more than one strength of tablets were kept or written on the medicine chart, if records made clear what was in use and only the packets and strengths of tablets used kept on the trolley. We saw that eye drop medication was managed properly but noted that one eye drop directions needed to include which eye(s) were to be treated. There were safe arrangements for the storage of medicines and these were tidy and well organised. We were concerned to find on the medicine trolley two dropper bottles that were only labelled with people’s names but not what they contained. We were told these were olive oil ear drops. We told the manager to obtain proper supplies from the pharmacy. Mrs McKeever had taken action since the last inspection to keep the medicine fridge locked. Sometimes daily temperature records showed 10°C which is above the maximum (8°C) for medicine fridges. This needs to be monitored carefully and suitable action taken if this is a persistent problem otherwise the potency of medicines could be affected. We pointed out that a number of the products kept in the fridge could in fact be kept safely at room temperature. Where skin treatments were kept in bedrooms there were general risk assessments in care files. Staff need to make sure in using these that they have considered each person’s individual circumstance and risk. Since the last inspection arrangements for storing controlled medicines have been upgraded. We pointed out that the wall fixings were not correct. The manager made immediate arrangements to deal with this and confirmed this was put in place the next day. Our checks of these medicines did not show any problems. Records showed medicines were administered at the right intervals and daily stock counts recorded showing that all the medicines were accounted for. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 18 A pharmacist from the Primary Care Trust had recently carried out a review of the use of medicines for people living in the home and changes made in conjunction with the GP. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 19 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People appeared content to follow their own solitary interests yet further activity provision has been developed. People are able to follow their preferred routines and receive visitors as they wish. Meals are being further developed in order to enable greater choice and satisfaction. EVIDENCE: People told us that there were various social activities provided by the home. They said they were able to choose whether they joined in or not. Some people told us that they preferred to stay in their bedrooms. One person said ‘there are things going on but I generally fill my time with reading and my visitors. I could join in and I think they would like me to, but I’m quite happy.’ Another person said ‘I’ll have a go at what ever is on. I generally have my coffee in my room and will go down [to the lounge] after that. I like the quizzes. We’ve also started going out to a farmhouse for tea. That’s really nice, as it’s a change of scenery.’ Another person told us that they regularly went to the local social group, which was held in the village. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 20 Within surveys, one person told us that there were ‘always’ activities they could join in with. They said ‘well arranged activities of various types and also enjoyed singing event – more please.’ Another person said there were ‘usually’ activities they could join in with. One person said ‘sometimes’ to the availability of activity provision. With the support of their relative, they said ‘more stimulating conversation for residents that are not of special needs but who need someone to talk to.’ Within our visit, we saw that staff spent time socialising with people. One staff member visited with their new baby, which proved very positive. We saw within one person’s care plan that they enjoyed a manicure and liked a particular station on the radio. We saw that the person’s nails had nail varnish on them. Staff had supported the person to have their radio on, as stated within their care plan. Mrs McKeever and staff told us that a large amount of work had been undertaken to record people’s life histories. Information about some people’s lives was displayed in the entrance area of the home. A notice explained that people’s permission had been gained to share the information. We saw a staff member talking to a person about their life history. We advised that the person be supported to decide what information they wanted to share and how they wanted it presented. This would enable people’s life histories to be unique to them. People had been supported to choose a photograph or picture of their choice for their bedroom door. There were examples of people’s favourite places, special occasions and/or family members. Some people had displayed a photograph of their ‘younger days.’ We saw that some people had laminated pictures of their family on the wall near to their bed. Mrs McKeever told us that the pictures were changed at regular intervals. This enabled people to experience their full benefit rather than storing them away. The AQAA stated ‘activities have improved with greater variety and flexibility to accommodate people’s needs.’ We saw that further developments were also planned. Mrs McKeever told us that the activity coordinator was now more established. They provided more one to one work with people in their own rooms. They also worked closely with the day centre staff. Mrs McKeever told us that people living at the home could join in with activities offered to day care members. This provided people with greater opportunities for social activity and interaction. People told us that they could make decisions and live their lives as they wanted to. One person said ‘they are very good at ‘leaving you to it’ but they are there if you need them.’ Another person said ‘oh yes, you can do what you like really. I have my own routine of getting up and having a very leisurely morning. They will bring you your meals and coffee so there’s no rush.’ We saw that some people were asked if they wanted to help lay the tables for The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 21 lunch. Within their survey, in relation to what the home does well, a staff member told us ‘they give the resident the choice to do a lot of different things.’ People told us that they could have visitors at any time. One person told us ‘my XX often comes to take me out.’ Another person said ‘my XX just pops in at any time. S/he can just come in and out whenever s/he wants. They don’t mind.’ In order to maintain important relationships, we saw that one care plan highlighted the need for staff to hold the phone to a person’s ear so they could hear their relative when they phoned. With surveys, people told us that they ‘sometimes’ liked the meals. Within discussion, people were more positive. Specific comments included ‘the food is always very good. They bring it to you,’ ‘it’s always good and hot. We have a choice and it always looks good’ and ‘I get on very well with the food. I’ve no complaints.’ Mrs McKeever told us that a new cook had recently started at the home. She said positive changes had been made and the new winter menu was in the process of being devised. Staff told us that people were given menu cards to make a choice of which meal they wanted. There were menus on the tables. These contained a range of traditional food such as chicken curry or Cornish pasty, beef and Guinness stew or vegetable crumble. We saw that the lunch time meal looked colourful, appetising and was well presented. People were well supported at lunchtime and staff were attentive to people’s needs. Staff sat with people needing assistance to eat and encouraged them through general conversation. We saw that if a person needed their meal liquidised, each item was liquidised separately. Some people had their meal in their room. We saw staff transport food on trays. All food items were appropriately covered. Mrs McKeever told us that meals are regularly discussed within ‘residents’ meetings.’ Any feedback is passed to the catering staff. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 22 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assured that any concern they raise would be taken seriously and resolved as quickly as possible. Clear systems are in place to minimise the risk of people experiencing potential abuse. EVIDENCE: The AQAA stated ‘the Trust has a robust policy and open approach to responding to complaints. Policies and procedures are in place and all staff are encouraged to respond in a non aggressive manner. The complaints procedure is made public to residents and their families at the time of admission and the complaints procedure is displayed in the main entrance to the home. All complaints are taken seriously. Once recorded, they are investigated and the findings shared with the complainant, as quickly as possible and within the allocated time.’ Mrs McKeever told us that since the last inspection, she has worked with staff to increase the profile of complaints and how they can be used to develop the service. She said staff are encouraged to treat any concern as a complaint in order for it to be fully investigated and resolved. She said that any complaint received is discussed with the senior team. Within the AQAA, we saw that five complaints had recently been made. All were waiting to be concluded. Mrs McKeever told us that the issues were not originally raised as formal complaints yet she felt they should be treated as such. She said she had met The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 23 with people and their relatives to discuss the issues raised. Measures had been put in place as required, to minimise further occurences. While a record of the complaints were in place, we advised that the complainant be informed of the outcome of the invesigation, in writing. Mrs McKeever told us that she had spoken to staff about fully recording any issues, which were addressed on a day-to-day basis. We advised that these be kept together rather than on people’s personal records in order to identfy any trends in complaints. Within surveys, people told us that there was someone they could speak to informally if they were not happy about anything. They said they did not know how to make a formal complaint. Mrs McKeever told us that while the complaint’s procedure was available in the entrance area and the service user’s guide, it would be talked about at the next ‘resident’s’ meeting. Within surveys, staff told us that they knew what to do if a concern was reported to them. At the last inspection, while acknowledging that systems were in place to safeguard people from abuse, there had been a very high number of thefts within the home. Following the inspection, further thefts occurred although there have not been any recent incidents. Mrs McKeever appropriately reported each incident to the Police and the local Safeguarding Adults Unit. We saw that there remained notices around the home, encouraging people to be vigilant and to store all money safely. Mrs McKeever told us that people were discouraged from keeping amounts of money on them or within their room without it being securely stored. Staff told us that they had completed training on adult abuse. They said they would immediately inform a senior member of staff if they suspected or witnessed an allegation of abuse. They said they had a copy of Wiltshire and Swindon’s safeguarding procedures, ‘No Secrets.’ The AQAA confirmed the systems in place to protect people. It stated ‘the rights of individuals are protected. All staff receive a copy of the No Secrets and Codes of Practice and attend the Vulnerable Adults training when commencing their employment with the Trust. All have been through the POVA and CRB process and have a clear understanding of their responsibilty to inform of any form of abuse or threat to the residents. They have to show knowledge in this area at the initial interview.’ The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 24 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from an environment that is clean, well maintained and furnished to a good standard. EVIDENCE: People have a single bedroom on the ground or first floor. There is a passenger lift or various staircases giving access to the first floor. Those rooms visited were personalised to a high degree. People had brought items of furniture with them, on admission. All had a number of important possessions including pictures and photographs. Some people had their own telephones and a key to their room. Communal areas consist of a large dining room with various seating areas. There is an additional lounge which is used to accommodate day care clients during the week. There is a hairdressing room and additional seating areas The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 25 within the corridors. We saw that all communal areas were comfortable and maintained to a good standard. The AQAA stated that there had been various developments to the environment since the last inspection. We saw that the laundry had been totally refurbished and the programme to renew the home’s roof had been completed. Many of the bedrooms had received new furniture. En-suite facilities had been built onto two bedrooms. Two communal toilets had been relocated and two toilets had been refurbished. The lounge and dining room had been redecorated and new carpet had been fitted. The carpet in one of the upstairs corridors had been replaced. There had been new curtains in the corridors and new blinds in the lounge and dining area. We saw that further improvements were also planned. The AQAA stated that a wet room was to be installed and commodes were on order to replace dated models. The upstairs sitting room and the kitchen were to be redecorated. More bedrooms were to be refurbished. A staff member told us that the housekeeping staff now have a designated area of the home to be responsible for. They said they thought this to be a better system than the one they had previously. A Head Housekeeper had also been appointed. They said the cleaning schedules had been reviewed and the allocation of work was ‘workable.’ They said they had the equipment to do their job effectively and were trained in the use of the cleaning substances they used. Staff told us that they had access to disposable protective clothing as required. Within surveys, people told us that the home was usually fresh and clean. Within their survey, one staff member said ‘the general housekeeping around the home could improve e.g. cobwebs and dust. Also the kitchen being kept clean and plates washed properly.’ During our visit, the areas we saw were cleaned to a good standard and there were no unpleasant odours. There were soap dispensers and paper towels in all toilets and communal bathrooms to minimise the risk of infection. We saw that an external contractor had recently undertaken a ‘deep clean’ of the kitchen. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s safety and care needs are now more efficiently met through the allocation of staff to specific areas of the home. People are protected by a robust recruitment procedure. People benefit from a well trained, motivated staff team. EVIDENCE: A member of staff told us that there were generally six or seven staff on duty during the day. The staffing rosters confirmed this. The staff member said this usually meant that three staff were allocated to work with people on the first floor. Two staff worked on the ground floor and one member of staff stayed in the communal areas. The staff member said this worked well. They said ‘yes, there are always enough staff, just perfect. There’s not any rushing around. We can spend time talking to people and also get our work done. It’s good.’ People told us that there were generally enough staff on duty although one person said ‘sometimes it can be difficult and you have to wait for the staff to finish what they are doing before they can help you. This is worse if you need two staff, as you have to wait for both of them to be free.’ Mrs McKeever told us that since the last inspection, a Head of Care has been appointed. There had also been a new post of Head Housekeeper. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 27 Within surveys, people told us that staff were ‘usually’ available when they needed them. They said the staff ‘usually’ listened and acted upon what they said. One person said ‘the Cedars is a happy home where the staff have time to talk to us when we are having a bad day.’ Another person said ‘they help people like me to adjust to being in care. It is very hard when you have been independent all your life, to suddenly have to be cared for.’ Other comments were ‘most of the staff are very kind and caring’ and ‘The Cedars do a very good job. The staff are very friendly and helpful.’ Staff within their surveys said there were ‘usually’ enough staff to meet people’s needs. One staff member said ‘general care for the residents is very good, as long as we are fully staffed.’ Another staff member said ‘residents who need nursing care seem to be left a long time and given full personal care, as some staff do not seem to know what to do.’ We spoke to Mrs McKeever about this comment. Mrs McKeever said she was not aware of this although would raise it at the next staff meeting. We saw staff working within different areas of the home and therefore all call bells were answered without delay. Unlike the last inspection, we saw that staff interacted well with people. They were polite and attentive. There was lots of general discussion and some staff sat with people at different times of the day. We saw that some staff answered people politely by saying ‘no problem, it’s a pleasure’ or ‘you’re welcome.’ We looked at the recruitment documentation of two recently employed members of staff. The files contained the required information, which showed a robust recruitment procedure. There was a photograph, an application form and two written references. We saw that one reference had been returned due to the referee claiming that they did not know the person. Mrs McKeever had confirmed and verified the reasons for this. There were details of the person’s medical health, which ensured they were fit to do the job. Each staff member had been checked against the Protection of Vulnerable Adults register before commencing employment. Criminal Record Bureau (CRB) certificates were in place as required. These checks ensured the staff were suitable to work with vulnerable people. Within their surveys, staff told us they had a thorough recruitment process before starting work at the home. They said their induction covered everything they needed to know to do their job. They said they often received support from their manager and undertook regular training, which was relevant to their role. We spoke to one newly appointed staff member. They told us they were still within their induction period. They said they were allocated a member of staff to work with throughout each shift. They said they could ask questions of any staff member, at any time if they were not sure of something. They said they found all staff to be very helpful. The staff member told us that during their The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 28 induction so far, they had completed manual handling and fire safety training. They said they were planning to start their National Vocational Qualification (NVQ) after their induction programme had finished. Within the AQAA it stated ‘we maintain training records at the home and the Trust Training Manager visits quarterly to monitor this. We consistently exceed the 50 NVQ ratios required. Our staff are enthusiatic about training and development opportunities. We have a training co-ordinator and e-learning champion who coaches staff when undertaking courses on the computer. Training records and reports are held electronically.’ Staff told us that training is given high priority. One member of staff told us ‘training, we are always training. There is always something going on.’ Another staff member said ‘they are very good at keeping everyone up to date. We have lots of mandatory training but also do other things as well.’ Within training records we saw that recently, staff had completed training in infection control, fire safety, dementia care and ‘end of life’ care. Some staff had completed nutrition and wellbeing training. We saw that hearing and sight impairment training had been arranged for the following month. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 29 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from an experienced manager. Systems are in place to regularly audit and improve the service provided. The safe keeping of people’s personal monies is well managed. People’s wellbeing is promoted through clear health and safety systems. EVIDENCE: Within the AQAA it stated, ‘as the Home Manager I have 8 years experience in working with older people in residential care. I have achieved NVQ level 4 in management and hold a nursing qualification, accredited Dementia training, and a first aid at work qualification. The Trust reviews the Managers personal development on a regular basis and accesses training where identified.’ Mrs The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 30 McKeever told us that since the last inspection, she had undertaken training in the new care planning systems and evaluation. She had also completed an ‘End of Life’ course, training in the Deprivation of Liberty and a four day leadership and management course. Mrs McKeever told us that she regularly researched particular topics, in order to maintain her professional nursing qualification. She said she was planning to attend the organisation’s Dementia Care conference in October 2009. The home has a quality assurance system that is used within all of the homes within the organisation. The system consists of various audits and questionnaires. Mrs McKeever told us that she had recently had a full organisational audit. She said the findings were much better than last year’s audit. We saw that fully completing care charts had been identified as a shortfall. Mrs McKeever told us that regular ‘resident’ meetings continue to be held. We saw minutes of the meetings on the notice boards around the home. We saw that senior managers and other care home managers visited the home on a monthly basis, as part of regulation 26. Records were in place to demonstrate the areas of discussion, which had taken place. As stated earlier in this report, we saw posters around the home encouraging people to keep their money securely stored. Some people had placed small amounts of their personal monies, for the home to hold safely. We looked at the systems for managing this and checked a sample of cash amounts. The cash corresponded with the balance sheets. Only senior staff had access to the storage of people’s personal monies. We saw that two members of staff signed to demonstrate each transaction. Mrs McKeever and representatives from the organisation regularly audited the systems. We saw that expenditures generally covered hairdressing and chiropody costs. Mrs McKeever told us that trips out and any associated costs such as drinks and meals were paid for by the home’s amenity fund. The AQAA stated ‘the home protects the staff, residents and visitors safety and well being by adhering to regulations and legislation, having comprehensive risk assessments which are regularly reviewed and updated and by ensuring all staff are up to date with mandatory training including first aid, food hygiene and moving and handling.’ We saw that there were many health and safety policies and procedures in place. Ms Yeates told us that she addresses health and safety on a monthly basis, during her visits to the home. Due to the organisation’s regular auditing, we did not look in depth at the risk assessments in place. We advised that an assessment be completed in relation to one person’s room, which had access to the loft area. We saw that the risk assessment in relation to smoking had not been signed or dated. The assessment highlighting the risks associated with hot drinks was not dated either. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 31 We saw that staff were up to date with their mandatory training such as first aid, manual handling and food hygiene. Mrs McKeever told us there were two manual handler trainers within the staff team. She said they did regular training sessions with staff to ensure that the appropriate techniques to move people safely were used. Staff told us that while they received regular training, they could also ask the manual handler trainers if they were not sure of something. Staff told us that they had developed a new fire board to show who was in the building at any one time. The fire log book showed satisfactory testing of the fire alarm systems. We saw that external contractors tested the water temperatures on a monthly basis. Despite this, we noted that there were two hot water outlets, which were above the recommended temperature of 43°C. Mrs McKeever told us that she would ask the contractors to return to check the temperatures of all hot water outlets. We saw that the call bell system and the portable electrical appliances had been tested as required. At the last inspection, we saw that there had been a high number of falls. We advised that the accidents be monitored in order to identify any trends or specific risks. Mrs McKeever told us that a new system of monitoring had been put in place. She said by looking at trends, the number of falls had been reduced. We looked at the accident book and saw that staff were now recording greater detail when documenting an incident. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 32 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 X 3 X X 3 The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 33 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12(1)(a) Requirement Staff must ensure that they fully complete all care charts and evaluate them at the end of the day. This is to ensure that people have adequate food and fluid intake. Staff must ensure that if required, people are supported to change their position at the agreed times, which are identified on their care plan. This is to minimise their risk of developing a pressure sore. Conduct a thorough review of all medication arrangements (including staff training) and put into place any changes found necessary to make sure that there is always safe administration of medicines. (This is specifically to address the issue of medication errors included in the text of the report.) This is needed to help make sure that people living in the home always receive the correct medication as prescribed and the risk of errors is reduced to a minimum. DS0000028140.V377887.R01.S.doc Timescale for action 10/10/09 2 OP8 12(1)(a) 10/10/09 3 OP9 13(2) 30/11/09 The Cedars Version 5.3 Page 34 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 Refer to Standard OP7 OP7 OP7 OP38 OP38 Good Practice Recommendations The duplication within care plans should be reduced to enable staff to have clearer access to key information. When staff evaluate a person’s care plan, they should reflect on the stated intervention so that it remains relevant and effective. Staff should not use subjective language within daily records and should clarify terminology such as ‘full care given.’ Staff should monitor hot water temperatures in addition to external contractors, to ensure all are maintained at a safe temperature. A risk assessment should be undertaken in relation to the loft area, which is accessed from a person’s room. All assessments should be signed and dated. The Cedars DS0000028140.V377887.R01.S.doc Version 5.3 Page 35 Care Quality Commission Care Quality Commission South West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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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