Inspection on 01/11/05 for Cedar Falls Nursing Home

This inspection was carried out on 1st 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 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

Cedar Falls Nursing Home 19/07/06

Cedar Falls Nursing Home 20/02/06

Cedar Falls Nursing Home 15/12/04

Cedar Falls Nursing Home 03/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Cedar Falls Nursing Home Little London Road Spalding Lincs PE11 2UA Lead Inspector Jean Cope Unannounced Inspection 1st November 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cedar Falls Nursing Home Address Little London Road Spalding Lincs PE11 2UA 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) 01775 713233 01775 766062 Tanglewood (Lincolnshire) Limited Mrs S Woods Care Home 93 Category(ies) of Old age, not falling within any other category registration, with number (93), Physical disability (12) of places Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Physical Disability (PD) Registration Category will apply only to the bungalows. Bungalows accommodating service users with a physical disability must be single occupancy. Bungalows accommodating service users with a physical disability must have environmental adaptations and equipment provided, according to individual assessed needs. 15th December 2004 Date of last inspection Brief Description of the Service: Cedar Falls Care Home is situated in the market town of Spalding, which provides a wide range of amenities including shops, pubs etc. It is part of the Tanglewood Healthcare Group, which operates five care homes in Lincolnshire. The home comprises a two storey main building, with a lift to the first floor, and 12 bungalows situated in the grounds. The home is registered for 69 older people in the main building, and 24 in the bungalows, although the bungalows are single occupancy at present. All bedrooms are single occupancy with the majority having en-suite facilities. The home is decorated and furnished to a high standard, and has 9 quiet sitting areas. The extensive gardens are laid to lawns and flower- beds, with outdoor seating provided. The bungalows were also registered to accommodate up to 12 people with physical disabilities earlier in the year. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place with the assistance of the manager, Shirley Woods. One inspector and another non-inspector colleague undertook the inspection over a six hour period. The inspector toured the building, spoke with two members of the care team and the manager, three visiting relatives and seven residents living in the care home. The main method of inspection used was called case tracking which involved selecting three residents and tracking the care that they receive through the checking of their records, discussion with them, the care staff and observation of care practices. What the service does well: What has improved since the last inspection? Areas in the home, particularly the communal areas have been re decorated and individual rooms are decorated on an ongoing basis. A new deputy manager has been appointed to work in the home and the manager and the training officer have put in place a staff support system to assist new staff members following induction training. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 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 Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 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 the following standard(s): 3,5 and 6 Residents can be sure that senior staff will assess their needs to ensure that the home can meet them, and prospective residents and their relatives are encouraged to look around the home before they move in. EVIDENCE: The manager or senior staff visit people to assess their needs prior to them moving into the home. This can take place in the person’s own home or in a hospital setting. If the admission is arranged as an emergency by social work staff, staff from the home request assessment documents and care plans to be sent to the home prior to the admission to ensure they have sufficient information. Relatives visiting the home said that they had had the opportunity to look around the home prior to their relatives moving in to the home. One resident said that they had looked around the home prior to them moving in and felt that the staff would support them in living as independently as possible. The home does not provide a service for intermediate care. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 9 Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 7, 8, 9 and 10. Residents can be sure that they have a plan of care drawn up for them and that this will include their personal choices and preferences. Staff will support residents who wish to look after their own medications for as long as possible. EVIDENCE: Each resident living in the home has a care plan, which is reviewed on a regular basis. Care plans give details of the care that residents need, resident’s personal choice and preferences and how they like to spend their time. There was evidence that doctors and specialist nurses were called when necessary to advise staff about individual residents’ care needs. Residents are able to look after their own medication and are provided with lockable facilities. Staff undertake a risk assessment to ensure that residents will be able to take their own medication safely and support residents when they need it. The home’s pharmacist packs medications ordered by the home in a monitored dosage system, which the home stores safely. Nurses administer medication to residents requiring nursing care and care assistants administer medication Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 11 to residents requiring personal care only. Carers administering medication have received training and qualified nurses continue to check that care staff are competent to do so. A new medication policy is being written to include the new procedure for disposing of medication. Fifteen comment cards were received from residents, thirteen of them confirmed that their privacy and dignity were respected and care staff were seen to knock on doors prior to entering residents’ own rooms. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 12, 13 and 14. A range of activities is provided to occupy residents’ minds and their independent lifestyles are promoted wherever possible. EVIDENCE: There is a range of activities available for residents to join in with. These include, needlecraft sessions, games afternoons, coffee morning and bingo. The home has an activities co-ordinator who works full time who also takes residents out on shopping trips. There are also regular visits from outside entertainers. Church services are held in the home on a weekly basis. The hairdresser visits the home on a weekly basis and the chiropodist on a monthly basis. Family and friends visit the home when they wish and said that they were made to feel welcome and can have a meal with a resident if they wish. The local bus service stops regularly at the home, which one resident had used in the morning to go into town to do some shopping. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 16 and 18 Residents and their relatives know how to complain and to whom they should complain and that their complaints will be responded to within the agreed timescale. EVIDENCE: The manager had received one complaint, which had also been sent to the Commission. This had been responded to within the agreed timescale. No complaints were received on the day of the inspection. Fifteen comment cards were received from residents living in the home, all of them said that if they were unhappy with their care they knew whom to speak to about it. The home’s complaints procedure is posted on the notice boards. Staff training is provided on abuse on an ongoing basis, and staff are made aware of what constitutes abuse and how to protect residents from abuse. The manager has a copy of the local authority’s adult protection procedure. How to use this procedure and how to refer alleged cases of abuse were discussed with the manager during this inspection. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 19, 20, 21, 22 and 26 The home provides a safe, homely and comfortable environment for residents who are able to bring their personal belonging with them if they wish. EVIDENCE: The home was clean, tidy both inside and outside, and was maintained to a very high standard. There are plenty of communal and quiet sitting areas where residents can meet together or with their relatives, which are bright and airy. Two smoking lounges are also provided, one on each floor. There are eight bathrooms in the home; two of the bathrooms provide assisted baths, with a third being accessible to use a hoist in. Staff commented that additional shower facilities would be useful. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 15 The home smelt pleasant because staff are committed to ensuring that all unpleasant odours are dealt with immediately. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 28 There is a stable staff group who understand residents’ needs and they provide consistency of care. EVIDENCE: The manager is very aware of ensuring that the home is run with a good mix of skilled and new staff. The home is always staffed by qualified nurses with the support of up to 11 care assistants, with two other care assistants looking after residents residing in the bungalows during the day. The home is now staffed by a stable workforce and uses no agency staff. A relative commented on the fact that ‘the staffing situation has now stablised’. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, and 38. The home is run by an experienced and qualified manager and stable staff group who do their best to ensure that the home is run in the best interest of the residents. EVIDENCE: A registered manager who is well thought of manages the home. The manager holds regular residents’ meeting the last one was in July 05 when eight residents met with the manager and the entertainments officer. Positive comments were voiced as well of requests for changes. One resident confirmed that their request had been responded to. Regular staff meetings, head of department meetings and the manager’s weekly audit also work towards running the home in the best interest of residents. The manager is constantly reviewing the number and skill mix of staff in relation to the needs of the residents living in the home. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 18 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 3 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 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 19 none 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 OP9 Regulation 13(2) Requirement Prescribed creams must only be used for the person intended and must not be left in communal rooms. Timescale for action 01/11/05 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 Refer to Standard OP21 Good Practice Recommendations It is recommended that the registered person conduct an audit of the bathing facilities within the home. Cedar Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Falls Nursing Home DS0000002636.V263755.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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