CARE HOMES FOR OLDER PEOPLE
CEDAR LAWN Cedar Close Stratford On Avon Warwickshire CV37 6UP Lead Inspector
Jean Thomas Unannounced 21 July 2005 09:30 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 LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Cedar Lawn Address Cedar Close Stratford On Avon Warwickshire CV37 6UP 01789 205882 01789 292752 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) Methodist Homes for the Aged Ms Patricia Anne Dean CRH Care Home 34 Category(ies) of OP Old age registration, with number of places CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 18 January 2005 Brief Description of the Service: Cedar Lawn is a residential care home for older people managed by Methodist Homes. The home is registered for 34 older people requiring personal care and accommodation. The home is close to the town centre of Stratford Upon Avon and the facilities offered within the town. Buses run regularly nearby. The organisation has almost 50 care homes throughout England and Wales. Cedar Lawn was originally a large private dwelling, which has subsequently been converted and extended to provide residential accommodation suitable for older people. The main lounge and dining area are centrally located on the ground floor, however service users may also use the reception area or a sitting room on the first floor. In addition the home has a small quiet/prayer room on the first floor. All facilities, with the exception of five bedrooms, can be reached without the need to negotiate steps. Car parking is available at the front and side of the home. Extensive gardens are to the side of the home. CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 8 hours and is the first of two inspections to be conducted this year. A tour of the premises was undertaken, looking at all communal areas, bedrooms and service areas, such as the kitchen, lounges, bathrooms and bedrooms. Three residents’ care plans were examined which gave an overview of the care prescribed and delivered, these records also contained information as to how any identified health care needs were being met. Records related to staff recruitment, induction, and training were examined along with records related to the upkeep and maintenance of the home. Medication administration and records related to this area were also seen. Six staff, nine residents and two relatives were spoken to. What the service does well:
Residents said they were well cared for by a team of staff who worked hard and who were kind and sensitive to their needs. The majority of residents also said that they had settled at the home and were happy with the care, support and facilities available to them. The home has good quality assurance systems in place, these include an annual survey, a rolling programme of internal audits and residents’ meetings. The care and support provided by the staff is of a good quality and is appreciated by the residents. The staff spend time with the residents and talk about a variety of topics and show an understanding and caring attitude. The home provides a range of therapeutic activities that are popular with residents. The residents have good access to medical care and other health professionals. Meals are varied and nutritious, a range of specialist diets e.g. diabetic, vegetarian are available on request. Residents said that the meals were excellent and that there was always an alternative to what was on the menu. The cook regularly consults with residents to ascertain and act upon their
CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 6 views and opinions, on both the quality of the food and on the menu. There were no complaints. The home is clean, well maintained and free of offensive odours. Residents are encouraged to personalise their rooms and to bring personal possessions and small items of furniture into the home with them. A significant number of staff hold a National Vocational Qualification (NVQ) in social care or equivalent. Residents are encouraged to participate in a range of activities. Five residents spoken to said how much they enjoyed the activities. During the day a number of individual and group activities were seen e.g. music and movement, and word search games. The staff spend time with residents and talk about a variety of topics and showed an understanding and caring attitude. What has improved since the last inspection? What they could do better:
Health and safety in the home is generally taken seriously, however greater effort needs to be made to ensure that where appropriate, individual risk assessments are completed, notably for the prevention of falls, manual handling, nutritional screening, self-administration of medication and the use of bed sides. Failure to bring about improvements in the risk management process, place residents at risk.
CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 7 In order to promote the health, safety and welfare of residents improvements to fire safety practices and drills are necessary, regular in house training should be introduced and should include, a record of the date and time the training occurred, what was involved and the names of those taking part in the exercise. In the absence of any involvement by social services, staff at the home carryout the initial assessment of care needs, which is completed prior to admission to the care home. The format used requires further development to make sure the assessment fully reflects the individuals care and support needs and as such forms the basis of the care to be delivered. Information should be readily available to make sure residents requiring support have easy access to professional independent advocacy services. 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 LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 8 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 LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 9 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 and 6 Pre-admission assessment information falls short of what is required to determine whether individual care and support needs can be met. EVIDENCE: In the absence of a care management assessment (undertaken by Social Services) the home uses their own assessment format, which when completed fails to adequately reflect the individuals’ care and support needs. More information could be obtained regarding residents’ life histories, which is especially pertinent for those residents who have sensory loss or some mild cognitive impairment. Visits to the home often take place prior to admission. Following a visit a short stay is arranged before a decision reached as to whether to move into the home permanently. The home offers trial periods for up to 8 weeks and also encourages day visits prior to admission. Intermediate care is not provided by the home.
CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 10 The home has the capacity to meet the needs of residents with appropriately trained staff and equipment. CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 11 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 and 10 Residents have good access to health care and relevant health professionals. Residents are treated with dignity and respect and although individual care plans do not accurately reflect the resident’s care and support needs these needs are generally being met. EVIDENCE: Although each resident has a plan of care, further work is required to ensure care plans include the range of needs identified and details of how these needs are to be met. Care records hold evidence of consultation with other health care professionals but this information is not always included in the plan of care, and this may result in unmet needs. One resident being cared for in bed was receiving appropriate pressure area care, regular fluids and a soft and varied diet suited to her needs. Equipment provided by the Community nurse included a hospital bed, a pressure-relieving mattress and padded bedsides. Further work is required to ensure nutritional screening is undertaken at the point of admission and monitored on a regular basis, this should include, where appropriate regular weight checks to make sure that any changes identified are responded to in a timely and appropriate manner.
CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 12 The absence of risk assessments for the use of bedsides is unsafe and may place residents at risk of harm or injury. Although safe policies and procedures are in place for the safe handling and administration of medication there were two discrepancies noted, one when antibiotics had been signed for but not given and a 5mg tablet of diazepam was missing and unaccounted for. In order to ensure the safety and welfare of residents only appropriately trained staff administer medication. A number of residents administered their own medicine but individual risk assessments deemed as necessary to determine the residents’ physical ability and cognitive understanding had not been undertaken, therefore placing residents at risk of harm of injury. A significant number of residents spoken to said that staff treat them with kindness and respect. A number of residents said they had a key to their private room whilst others said they had declined, preferring instead to leave their door unlocked. Staff knock on residents doors before entering and all personal and health care needs are met in the privacy of the residents room. CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 13 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) 12, 13, 14 and 15 Meals provided are varied and offer a balanced diet for residents. Arrangements and management of mealtimes are well organised and present no obvious risks to the safety, well being and comfort of residents. The current arrangement for activities and entertainment provide adequate recreation or motivation for residents. Residents are able to maintain contact with family friends and other parties as they wish. EVIDENCE: Residents spoken to said that they were free to make their own decisions about their daily lives and that staff respect these decisions. The home provides a range of therapeutic activities, which are enjoyed and well attended by residents. A menu is displayed on each dining table so residents are aware of what choices are available. Although there is only one main meal identified on the menu at lunchtime residents spoken to told the inspector that an alternative was offered if requested. The cook consults with residents each day to ask their views about the menu and the quality of the food. Residents spoken to commented that the food was “wonderful” “Plenty of it” “nothing was to much trouble” “you could have what you liked”. The home does not include a cooked breakfast on the menu, residents spoken to say they didn’t want a cooked
CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 14 breakfast, but were of the view that they could have one if they chose. A number of specialist dietary needs can met including, diabetic, low fat, soft and liquid diets as well as vegetarian. The kitchen is clean, well managed and stocked with a wide variety of provisions. The dining room was warm spacious and airy with dining tables set in an attractive manner. CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 15 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 and 18 Complaints are handled objectively. Residents and relatives are confident that their concerns will be investigated. Working and Care practices observed indicate that residents are protected from abuse. EVIDENCE: The home has a written complaints procedure, which is clear and all complaints are responded to within 28 days. Details of the complaints procedure are included in the Service Users Guide and displayed at strategic positions within the home. The home maintains a complaints, comments and suggestions book, this contained a number of entries mainly comments and suggestions. The last recorded complaint was 31st May 2005. Minutes held of residents meetings showed that the complaints procedure had been discussed. Relatives and residents spoken to knew about the complaints procedure and felt that the manager deals with complaints appropriately. Residents spoken to said they felt safe living at the home. Staff spoken to were aware of what may constitute abuse and should they have cause for concern, would report any issues to the manager immediately. Staff have undertaken some training on adult protection issues and further training has been identified as a staff training need for this year. Some staff were not aware of the Department of Health’s guidance document “No Secrets”, or the term whistle blowing. Complete awareness, is necessary in protecting residents from risk of harm. CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 16 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) 19 and 26 The communal areas and individual rooms are such that generally residents have access to a safe and comfortable environment. EVIDENCE: The rooms of the residents case tracked were clean and comfortable with personal possessions on display. Furniture within the rooms was of a good standard and gave a homely feel with many having personalised their rooms. One resident spent a lot of time in her room and found it very comfortable having her own belongings around her. The indications were that the home had specialist equipment for moving and handling residents and mobility aids, with adequate numbers of bathrooms. The communal areas, such as the lounges and dining areas were pleasantly furnished and, although the large layout of the home could cause difficulties, the indications were that staff ensured that residents in the communal areas were supervised. The home was clean and tidy and free of any offensive odours.
CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 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 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 and 30 Staffing levels were in sufficient numbers and skill mix, with indications that residents’ needs were being met appropriately. Recruitment procedures are thorough. EVIDENCE: Several residents were spoken to about staffing, both in groups and individually. The general view was that needs were met with comments made that staff were “patient and always helpful” “nothing was too much trouble” and “staff are very caring.” Staff spoken to felt that generally staffing levels were adequate and since more staff had been employed the number of agency staff used was likely to reduce. One visitor felt that staffing was generally satisfactory and the needs of her relative were being met. On the day of the inspection there were sufficient numbers of experienced and qualified staff available to meet the individual and collective needs of residents. There were a senior care worker, three carers, a cook, a kitchen assistant, two domestics, a trainee carer shadowing an experienced and competent worker as part of their induction programme. Alarm calls were answered promptly during the inspection. Three staff members’ recruitment records held the information required to ensure the safety and protection of residents. Criminal Record Bureau (CRB) disclosures and Protection Of Vulnerable Adult (POVA) checks are held centrally and were not therefore available for scrutiny on the day of the inspection.
CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 18 Documentation issued by Human Resources held confirmation details of CRB disclosures, including the date the disclosure was received and whether or not it was clear. CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 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 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) 31,33,35 and 38 Residents are involved in quality audits and their opinions and views used to develop the running and direction of the home. Residents’ monies and any valuables held are safe and their financial interests are safeguarded. Although the home promotes a range of health and safety policies and procedures there are a number of shortfalls that place residents at risk. EVIDENCE: Service users spoken said that the manager was cheerful, approachable and always had time to listen. Staff spoken to said the home was well run, took into account the needs and wishes of residents, and that the manager did a good job. Quality audits are in place and are undertaken each year and include an annual survey, a rolling programme of internal audits and residents meetings. Residents, staff and visitors made positive comments about the team, this was
CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 20 supported by the findings of the annual residents’ survey. The overall findings supported the view that the home was generally well run. Further information beneficial to the quality audit should be obtained from other professionals that work alongside the care team, i.e. doctors, dentists, district nurses. In order to safeguard residents’ financial interests staff adhere to agreed policies and procedures used for the safe handling of residents’ monies and property. Records and receipts are held of all financial transactions and of property handed over for safekeeping. Secure facilities are provided for the safe keeping of money and valuables on behalf of the resident. A range of health and safety policies and procedures are in place to ensure the health, safety and welfare of residents. Staff have undertaken a range of health and safety training that includes, moving and handling, first aid, Control of Substances Hazardous to Health (COSHH) and infection control. A record of accidents and incidents is held in accordance with the requirements of Health and Safety legislation and by the Care Homes Regulations 2001. A fire door leading into the kitchen had been wedged open and a hazard sign not placed on a wet floor in one of the toilets. Both issues were addressed immediately by the manager as such practices are unsafe and place residents at risk of harm or injury. Risk assessments necessary to ensure the health, safety and welfare of residents have not always been completed as required. Activities that had not been appropriately risk assessed include, the prevention of falls, manual handling, nutritional screening, self-administration of medication and the use of bedsides. Failure to undertake risk assessments place residents at risk of harm or injury. In order to meet statutory requirements and to ensure the safety of people in the care home, improvements to the management of fire safety practices and drills are necessary. In order to be effective fire safety training must be regularly updated and include in house training policies and procedures. A written record of the dates and times training occurred, what was involved and the names of those taking part in the exercise should also be held. CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 x x 2 CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 22 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 3 Regulation 14 Requirement In the absence of a care management assessment, the intial assessment of care and support needs should be comprehensive, and should include those elements identified in the standard. The Registered Provider must ensure that risk assessments regarding the prevention of falls are undertaken in order to identify and as far as possible, eliminate risk to residents. Manual handling assessments and risk assessments for pressure sores and nutritional assessments must be undertaken. (Previous timescale of 01.02.05 not met). The Registered provider must also ensure risk assessments are undertaken for the use of bed sides. Where residents lack capacity, the Registered Manager must facilitate access to advocacy services (Previous timescale 31.01.05 not met). The Registered Provider shall by means of fire drills and practices at suitable intervals, that people Timescale for action 31.08.05 2. 7 13 (a) 31.08.05 3. 17 12 (1) (a) 31.08.05 4. 38 23 (4) (e) Immediate CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 23 working at the home and, so far as is practicable, residents are aware of the procedure to be followed in the event of fire. 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. Refer to Standard 7 15 18 Good Practice Recommendations Care plans should accurately reflect details of the residents care and support needs. A second choice should be included on the menu at lunch times. Staff should be aware of the Whistle Blowing procedure CEDAR LAWN E53 S4214 Cedar Lawn V235651 210705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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