Inspection on 22/11/05 for Cedar Court Nursing Home (Dementia Unit)

This inspection was carried out on 22nd November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cedar Court Nursing Home... 29/11/07

Cedar Court Nursing Home... 18/12/06

Cedar Court Nursing Home... 07/07/05

Cedar Court Nursing Home... 09/03/05

Cedar Court Nursing Home... 16/06/04

Cedar Court Nursing Home... 22/12/03

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cedar Court Nursing Home [Demential Unit] Bretby Park Bretby Derbyshire DE15 0QX Lead Inspector Vanessa Davies Unannounced 22 November 2005 10.00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Cedar Court [Dementia Unit] Address Bretby Park Bretby Derbyshire DE15 0QX 01283 211412 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Lindsay Mullholland Your Health Ltd Mrs Joy Theaker Care Home with Nursing 50 places Category(ies) of 50 Dementia registration, with number of places Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Option of admitting up to 10 persons aged 50 years and over within the total number registered. Date of last inspection 7th July 2005 Brief Description of the Service: Cedar Court care home has two units. The larger unit provides nursing and personal care for up to 50 persons aged 65 years and over with dementia, including up to 10 places for persons aged 50 years and over. Cedar Court is situated in a rural location near to Bretby village. Your Health Limited owns the home. The home is a two-story building; adapted for use as a care home. This unit has 34 single and 8 double bedrooms. 30 rooms have ensuite facilities. Access to the first floor is by stairs and a passenger lift. The unit has 3 lounges and dining areas on the ground and first floor, and has a large enclosed garden, which is accessible to service users. Although the ground floor is mixed sexes, there is a specific area on the first floor for male service users. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, in addition to addressing key standards not assessed at the previous inspection, the inspector was investigating an anonymous complaint made about the home. Information for the inspection was gathered by reading records. Looking around the home, observing staff with residents, speaking with a relative and speaking with the manager. What the service does well: What has improved since the last inspection? The repairs highlighted at the previous inspection have been addressed providing a pleasant environment. Following the appointment of a training officer, training of staff has become more frequent Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4,5 Assessments are completed prior to admission providing staff with information required to meet the needs of the service users. EVIDENCE: The inspector examined 4 care files, each file contained a detailed assessment of need and care plans developed from the assessments. The assessments of need covered all aspects of care. The relative spoken with stated that he and his family had visited the home prior to his wife moving in. He had been involved with the care plans and provided valuable information regarding her care. He was confident that following the visit and information gathering time, that the home were able to meet her needs. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 Detailed information is documented and a variety of other professionals are involved as necessary, all ensuring that the health and social needs of service users are met. EVIDENCE: As stated previously the assessments of need in the files examined covered all aspects of care. Detailed care plans developed from the needs highlighted were easy to follow and reviewed on a regular basis. There was evidence of input from the tissue viability nurse, dermatologist and GP. There were continence assessments and nutritional assessments completed. Consent forms for the Flu vaccine had been signed by relatives. Registered nurses administer all medication. The home keeps a record of medication received, administered and returned. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The meals in this home are reported to be good, offering both choice and variety for service users. EVIDENCE: The menu is documented on the notice board. Choices are offered. The relative spoken with stated that the quality of food was good and the staff did ensure dignity was preserved during meal times. The inspector did not examine the kitchen on this occasion. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Complaints are documented and investigated appropriately ensuring that service users and relatives are listened to and concerns acted upon. EVIDENCE: The CSCI have received an anonymous complaint about the home, this was investigated during the inspection and was not upheld. The manager keeps a clear complaints record, documenting the complaint, the investigation and the resolution along with dates, ensuring that all complaints are resolved within the 28 day timescale. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the standards within this section were assessed on this occasion. All key standards were assessed at the previous inspection in July 2005. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Staff training and stringent recruitment procedures ensure that the service users safety. EVIDENCE: The manager has 9 staff on duty throughout the day; 1 being a registered nurse and there is always a first aider on duty. There are 2 staff completing NVQ 4. There are a number of staff with NVQ 3 and a number with NVQ 2, this is an ongoing programme and staff who are not completing an NVQ are due to enrol. The inspector examined a cross section of staff files, all contained an application form, 2 written references and a Criminal Records Bureau check. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,38 Regular audits of the service ensure that service users are safe and care practices improved as necessary. EVIDENCE: Service users finances are kept securely and a clear record of monies deposited and withdrawn is kept along with receipts. Monthly safety audits are completed by the qualified Health & Safety person. Monthly maintenance checks are carried out. All staff have completed Fire training and Moving & Handling training. The fire alarms are checked weekly as is the emergency lighting. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x 3 x x 3 Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 16 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 18,28 Regulation 13 Requirement All staff must receive training on:1. prevention of abuse 2. prevention and management of aggression including use of restraint. (HIGHLIGHTED AT INSPECTION 17.07.03) The registered person must ensure that staff are appropriately supervised. (highlighted 16.06.04) Timescale for action 31.01.06 2. 31,36 18.2 31.01.06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 21 Good Practice Recommendations The Registered Person should pursue changing bathroom 4 to a shower room and addressing the issue with bathroom 7. Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 17 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cedar Court Nursing Home [Demential Unit] C52 C02 S2160 Cedar Court DE V248796 211105 Stage 0.doc Version 1.40 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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