Inspection on 19/07/06 for Cedar Falls Nursing Home

This inspection was carried out on 19th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 20/02/06

Cedar Falls Nursing Home 01/11/05

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 Kathryn Emmons Unannounced Inspection 19th July 2006 12:00 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.V304896.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V304896.R01.S.doc Version 5.2 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 713220 www.tanglewoodcarehomes.co.uk 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.V304896.R01.S.doc Version 5.2 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. 20 February 2006 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. Fees start from £305 per week. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during a weekday and the registered manager was present in the home. The registered manager assisted the inspector during the inspection. A total of four and a half hours were spent inspecting the home. The inspector toured the home and spoke with 7 staff, 1 visitor and 11 residents. Ten comment cards were received prior to the inspection. The main method of inspection used was called “case tracking” which involved selecting residents and tracking the care they receive through 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? All staff who have responsibility for medication administration have been enrolled on a distance learning course in addition to the in house training which is provided. The quality assurance programme is being further developed to include stakeholders outside of the home. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 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.V304896.R01.S.doc Version 5.2 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, 4, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are be confident that the home can meet their assessed needs. Information provided enables residents to make an informed choice regarding living at the home. No intermediate care is provided. EVIDENCE: Residents are assessed prior to being admitted to the home to ensure the home can meet assessed needs. Letters are then sent to the resident to confirm their needs can be met. This enables residents to be confident that they will be cared for when admitted to the home. Discussion with residents and one relative evidenced that a service user guide is given to prospective residents and their families. It was confirmed through Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 9 discussion with the manager that residents and their relatives are encouraged to visit the home prior to being admitted. Through case tracking it was evidenced that residents had contracts and terms and conditions of residence. The resident and the manager had signed these. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 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, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care records are accurate and enable staff to be clear on resident needs. Residents are satisfied with how their health care needs are met. Medication arrangements are satisfactory and provide a safe system for residents to receive their medications. Residents are treated in a valuing and dignified manner. EVIDENCE: Residents spoken with were aware that they had care plans in place and they confirmed they had been involved in these being written and reviewed. Risk assessments were in place for activities such as self-medication and the use of bed rails. Two residents spoken with were aware who their key worker was. One resident said “My key worker sees me every time they are working, even if they aren’t working on my floor”. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 11 Residents said they had access to the doctor and district nurses if necessary. During the inspection a resident was receiving a visit from a speech therapist. A chiropodist also visits the home. Through discussion with the care staff trainer and two care staff it was evident that training in the safekeeping and dispensing of medication was in place. Medication administration records were inspected and these had been completed correctly. Residents are able to self medicate their medication if they have undertaken a risk assessment which evidences they are safe to do so. During the inspection interactions were observered between staff and residents, residents were spoken to in an appropriate and valuing manner. Residents spoken with by the inspector indicated they were satisfied with the way they were spoken to by the care team. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 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, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to maintain and practise their cultural and religious beliefs. Residents are empowered to be as independent as possible and exercise control over their lives. Activities provided enable residents to have a varied daily life experience. Dietary preferences are catered for. EVIDENCE: The home employs an activities coordinator. Residents were spoken to regarding activities. Comments received were all positive and included “There is always something to do each day, today a quiz and on Friday strawberry tea on the lawn”. One visitor spoken with said that their relative was not able to attend the main lounge for activities but that the activity coordinator would spend some one to one time with the resident. The relative believed this indicated the homes understanding of the diverse needs of the residents who live at the home. The Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 13 activities available vary to enable all residents to be involved in purposeful activity irrespective of their abilities. Residents said they chose how to live in the home and one resident said the homes atmosphere was “free and easy”. Another resident said “ I get to see the hairdresser, get my shopping done for me and can spend time with people when I want”. Other examples given by residents included when the residents chose to get up in the morning when they took their meals and when they retired to bed. One resident said they were able to follow their spiritual beliefs and on the day of the inspection residents had been given the opportunity to attend a communion service held at the home. The menus provided by the catering team were varied and evidenced a nutritionally balanced diet was available. Residents have a choice of fresh fruit or biscuits with their drinks. A healthy option of main meal and dessert is available each day. The cook was spoken to who was able to evidence that they had a clear understanding of each resident’s dietary needs, including specialised diets. Residents spoken to said they enjoyed their meals and there was always choice available. One visitor said they had a meal in the home and the food was “always superb”. Comment cards raised no issues regarding the food provided and residents spoken to made comments such as “The food is always lovely and the type of food I would cook myself”. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 14 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are confident that their concerns will be listened to and investigated. Residents are protected from potential abuse by the homes safeguarding adults procedure and staff training. EVIDENCE: One visitor and all of the residents spoken with said they were satisfied that if they had any concerns these would be addressed. Residents said they would speak with the manager in the first instance and believed that any issues or comments would be resolved without delay. Staff training records evidenced that staff had received training in Safeguarding Adults and this training was updated yearly. The home has a safeguarding adults procedure in place. Those staff members spoken with were aware of the action to take if an allegation was made. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 15 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, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care is provided in a clean and tidy environment. Residents have comfortable furniture and pleasant surroundings. Equipment is in place to enable residents to be as independent as possible. EVIDENCE: The home was clean and tidy during the inspection. Domestic cover and laundry cover are in place 7 days a week. One comment card had been received which identified an issue regarding the cleanliness of one room. This room was inspected on the inspection and was found to be satisfactory. The resident who had raised the issue was spoken with and confirmed that since they had completed the comment card the cleanliness of their room had greatly improved. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 16 Residents and the visitor spoken to were satisfied with the cleanliness of their bedrooms. There were no adverse odours noted throughout the home. Communal areas were clean and tidy and furniture was in a good state of repair. The home was visited on a hot day and adequate ventilation was in place. External grounds had clear pathways with no trip hazards. Resident said that call bells were answered promptly. Equipment such as bath hoists, the shaft lift and handrails were well maintained. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 17 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, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An enthusiastic and motivated care team delivers care. Residents are confident that they are protected by the homes robust recruitment procedures. Training provided enables staff to have the skills and knowledge necessary to deliver safe care. EVIDENCE: Four of the comments cards received identified that at weekend’s resident felt that the home was short staffed. This was discussed with the manager who stated that recently even though sufficient staff were rostered on at the weekends sickness levels were higher then and it was often difficult to get agency cover. Ways of addressing the shortfall are currently being discussed with the responsible individual. The manager also confirmed that an additional member of staff was now being employed on each shift. When speaking with residents during the inspection residents said that staffing levels were ”ok” and “we get help as soon as we call”. Another resident said that they ”Sometimes get one of the carers to sit and chat” and “They are busy in the morning and at bedtime but I do get time with them in the afternoon”. Staff were spoken to regarding the training they had received to do their work. Job description form part of the induction process and staff were clear on their Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 18 job role and responsibilities. Staff said they worked well as a team and that the work was busy but that time was available in the afternoons to sit and speak with residents. The home employs a training coordinator who is responsible for planning training for all staff. Most staff had received all mandatory training and additional relevant courses have been attended. Training records evidenced that one staff that works part time was due to receive mandatory training and this had not been undertaken. The trainer confirmed they were aware of this and was making arrangements for this to take place. Recruitment processes are robust and four sets of staff recruitment files were inspected. These evidenced that all necessary checks had been undertaken. Staff who had recently commenced employment at the home were able to discuss the induction programme they had commenced and confirmed that they were working the shifts , but not included in the staff numbers. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 19 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, 35, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The resident’s benefit and have confidence in the fair and inclusive leadership style of the manager. Residents are kept safe by the homes health and safety polices. A quality assurance system provides residents with evidence of an improving and evolving service. EVIDENCE: The homes registered manager is Mrs Shirley Woods. Mrs Woods is a qualified nurse and has many years experience of working with older people and people who have physical disabilities. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 20 Residents and staff spoken with all made positive comments regarding Mrs Woods. One resident said Mrs Woods was “Very helpful and kind to every one”. Staff said that Mrs Woods “Is approachable and professional” and “Aware of what needs to be done for the home to run smoothly”. Residents also commented on how they were always consulted by Mrs Woods regarding activities and how improvements could be made to the services offered by the home. The home has a quality assurance programme in place, which includes obtaining the views of relatives and visitors to the home. The responsible individual produces a monthly report regarding how the home is operating. The homes administrator is responsible for safeguarding resident’s monies. Records are maintained of all valuables and money kept by the home for safekeeping. All polices and procedures were available for staff to read. These are updated regularly. It was evident that training in fire safety and moving and handling was taking place regularly. Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 21 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 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/A 18 4 3 3 X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X 3 3 X 3 Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cedar Falls Nursing Home DS0000002636.V304896.R01.S.doc Version 5.2 Page 23 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. 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