Inspection on 15/08/06 for Cedar Lodge Nursing Home

This inspection was carried out on 15th August 2006.

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 Lodge Nursing Home 26/08/08

Cedar Lodge Nursing Home 01/08/07

Cedar Lodge Nursing Home 10/01/06

Cedar Lodge Nursing Home 07/06/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Cedar Lodge Nursing Home 58-62 Kingsbury Road Erdington Birmingham B24 8QJ Lead Inspector Kath Strong Key Unannounced Inspection 15th August 2006 09:10 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 Lodge Nursing Home DS0000063476.V307639.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 Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedar Lodge Nursing Home Address 58-62 Kingsbury Road Erdington Birmingham B24 8QJ 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) 0121 350 3553 0121 384 4811 United Care Ltd Ms Sonia Seymour Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36) of places Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That the Home is registered for nursing care for a maximum of 36 service users for reasons of old age (OP) That in addition to the manager there is a minimum of one first level nurse and five care staff on duty throughout the waking day (14hrs). That at night there is a minimum of one first level nurse and two care staff on duty each night. Ancillary staff are to be employed in addition to the minimum staffing levels to cover catering, laundry and cleaning. Issues in respect of the premises are to be addressed within timescales as agreed with Mr Patel. 10th January 2006 Date of last inspection Brief Description of the Service: Cedar Lodge is a three storey property situated within the residential area of Erdington, West Birmingham. The home provides nursing care for up to 36 persons who are aged 65 years or over and may suffer from dementia, physical disabilities or terminal illness. The home is situated approximately one mile from Erdington centre where the main shopping facilities are located and a short distance from Sutton Coldfield. There is public transport within close proximity and Gravelly Hill interchange is convenient for those travelling by car. There is ample off road parking to accommodate at least seven vehicles situated at the front of the premises. Bedroom accommodation is available on each of the three floors, there are both single and shared rooms and some have en-suite facilities. Access to each floor is by a shaft lift and the home has a good supply of specialist equipment and mobile hoists for the benefit of residents. Meals are prepared on site as well as laundry facilities. The communal areas are located on the ground floor. The property has an extensive rear garden, which lends itself to outdoor functions during clement weather. The structure of the home provides good potential for further development. Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out the fieldwork over a period of one day. All of the keys standards and some others were assessed. Discussions were held with the quality manager and the registered manager provided assistance throughout the visit. Some of residents care plans were reviewed and one resident was case tracked to ensure that all identified needs were being met. Individual discussions were held with five residents, a relative and two members of staff. The delivery of care and interactions of staff with residents were observed during the day. Relevant documentation and aspects of staff allocations, recruitment, supervision and training were examined. Medication and health and safety arrangements were reviewed. A tour of communal rooms and a sample of bedrooms was carried out. At the conclusion verbal feedback was given to the quality manager and the registered manager. It is evident that the home continues to make good progress. What the service does well: What has improved since the last inspection? The four bedded unit has been converted and refurbished to a shared room with toilet and shower off, leading onto a meeting room with a vanity unit. The room is used by visiting professionals for consulting purposes and by the Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 6 visiting hairdresser on a regular basis. The room also houses a television for those residents who wish to watch a different programme from the majority. A written policy concerning tissue viability has been developed to assist trained staff in their duties. The recording tools for the monitoring and care of pressure ulcers have been improved to ensure delivery of appropriate standards of care. A Fire safety risk assessment has been collated for the safety of residents and staff. For the comfort of residents new curtains and bedding have been supplied for four bedrooms. New light fittings have been installed on the ground floor, which are more domestic in design and increase the homely appearance. A review of food storage has resulted in improved storage arrangements and firmer prevention of infection controls. The registered manager has commenced training for the Registered Managers Award. The two requirements made following the Fire inspection carried out in April have been addressed to maintain safety standards. 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 Lodge Nursing Home DS0000063476.V307639.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 Lodge Nursing Home DS0000063476.V307639.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): 2, 3, 4 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Information supplied to residents and professionals provides them with the ability to make an informed decision about the home. Residents are admitted following a comprehensive assessment, which ensures that the home is able to meet all of the identified needs of individuals. Staff training has not been provided to meet the registration category of the home or supply staff with the knowledge and skills to carry out their role. EVIDENCE: All residents are issued with a contract of terms of residency that provides all the relevant information. Prior to admission an enquiry form is generated and is regularly updated leading to a pre-admission assessment being carried out to assess all needs and ensure that the home has sufficient equipment and staff skills to meet those needs. Admission is not offered if it is determined that any needs cannot be met. New residents are given a trial period of 28 days and subsequent Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 9 review prior to the placement being confirmed. If residents are admitted to hospital a further assessment is carried out to check that the home can meet any additional needs that have been identified. The trained and care staff have received training courses which are pertinent to meeting the needs of the current client group. This along with the preadmission assessments indicates good practice in ensuring a knowledgeable and capable workforce are employed. It was noted that no staff have had training for dementia care. This oversight needs to be addressed in order to meet the registration category and to empower staff to deliver appropriate care to the client group. Cedar Lodge Nursing Home DS0000063476.V307639.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 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need to be more detailed to include personal preferences and relevant specific risk assessments developed to ensure that all care needs are being assessed and delivered. Medication practices promote health and reduced risks to residents but safe storage must be practised. Staff care and interactions observed respect and maintain the privacy and dignity of residents. EVIDENCE: Four care plans were sampled including the latest admission, which appear to have improved since the last visit. The depth and standard of recordings provide greater information and the layout of the files facilitate easy access to relevant sections. Written staff advice and guidance was noted for those residents who display difficult to manage behaviour. Some files also contain activities of daily living and recreational preferences. Further work needs to be carried out: • Those files that do not include activities of daily living and recreational preferences need to be reviewed Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 11 • • • • • • • The daily records for a resident states, “Thickener for all fluids, as risk of aspiration”. Another resident who was found to be at risk of aspiration was also identified. Risk assessments should be carried out without delay A file did not include consent for use of bed rails It was identified that a resident is prone to urinary tract infections but there is no care plan and monitoring tool in place A resident who has developed three pressure ulcers but only two care plans for them The monthly reviews for nutrition, Waterlow and weights must have the actual date documented. The practice of recording only the month should cease with immediate effect A review carried out with relatives present has not been dated There was no evidence that the life history and background is recorded. This is especially important for mentally ill residents in explaining behaviour trends. It was noted that a care plan supplied by a social worker and a review provided grossly inadequate details. The comments made by residents included, “Home is very good and staff are alright too, staff respond to requests, can make my own choices”. There is good documentary evidence that the services of many other external health care professionals are sought and advice given is acted on. The arrangements for the administration of medications are generally good but the safe storage of boxed medications needs to be assured. To fully protect residents from risks the home is advised to countersign any hand written medication instructions on MAR (medication administration record) charts. No adverse comments were received from residents about the way in which care is delivered by staff. Observation of practices and interactions with residents raised no concerns, thus ensuring the privacy and dignity of residents is maintained. Cedar Lodge Nursing Home DS0000063476.V307639.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 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents are mentally and physically stimulated and the activities meet the expectations of most residents. Opinions are encouraged and residents are consulted about the day to day running of the home. Dietary needs are catered for including special diets and choices resulting in provision of a varied and nutritious diet. EVIDENCE: The home has a seven day rolling programme of activities. There is an overlap of staff each afternoon, during this period a number of staff are allocated to provide group and individual one to one activities. The programme indicates a good range of activities are provided. External entertainers provide a gentle exercise regime, music and Karaoke and name that tune. Records are kept of each person’s participation and communications with relatives and friends. Two residents go out to day centres to increase their independent living and recreational skills. Some residents are taken out by their relatives to their homes or for a meal out and staff provide escort duties to those who wish to go for a walk during clement weather. Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 13 Regular residents meetings are held and minutes distributed accordingly. The agenda items indicate that residents are consulted about comfort facilities of the home and recreational preferences. A relative informed the inspector that she can visit at any time and she is made to feel welcome. The meal menu was provided; it includes details of four meals per day and offers choices for all of them. The cook advised that he has consulted with residents and is currently reviewing the menu. The meals offered gave a good range of choices and constitute a varied, balanced and nutritious diet. Specialist diets are catered for. Yoghurts and fresh fruit are available at all times. The serving of lunch was observed, meals were attractively presented, staff provided discreet assistance whilst encouraging residents to maintain their independence. It was noted that lunch consisted of two hot courses and those residents who were served in their bedrooms received both courses simultaneously. The home is advised to serve courses individually to ensure that food is served at the correct temperature for resident’s enjoyment of the meal. Comments received about meals included, “Food is quite good, food is very good and the chef comes to talk to us”. Cedar Lodge Nursing Home DS0000063476.V307639.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 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supplied with sufficient information about how to make a complaint. The arrangements for the protection of residents from abuse are not robust thus putting residents at risk. EVIDENCE: The written complaints procedure was on display and provides clear advice on how to make a complaint. This was evidenced by the fact that the home had received five verbal complaints since the previous inspection. Neither the home nor CSCI have received any written complaints during this period. It should be noted that three concerned the same resident. The complaints log indicated that these had been dealt with and documented appropriately and within the required timescale. The folder also contained a regular flow of compliments. The file suggested that residents and relatives readily express their thanks and concerns to assist the home in delivery of good standards of care. The written policy for adult protection has been amended and is satisfactory. Since the previous inspection the home has demonstrated that an allegation is conducted appropriately with the respective agencies being contacted. Most staff have received training in this aspect of care, all staff need to undergo training before this standard can be fully met. Cedar Lodge Nursing Home DS0000063476.V307639.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, 21, 22, 24, 25, 26 The quality outcome in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Warm, comfortable and safe accommodation is provided but recreational space and seating is limited and restricts choices. There have been good improvements in the assisted facilities but further works need to be carried out to some bathrooms. Generally the home is tidy and hygienic, mal odour persists in some bedrooms making it an unpleasant area for those residents. EVIDENCE: The lounge is not large enough to accommodate all residents. Advise was given that the registered individual is currently drawing up plans to increase the communal facilities; this will enable residents to make choices about where they would like to sit. The home offers good potential for development of additional communal space and the well laid out rear garden is extensive. The dining room has a pleasant outlook of the rear garden. Corridors are narrow resulting in multiple scuffmarks to the skirting boards and a bare light bulb on the second floor corridor was brought to the attention of the registered Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 16 manager. These items need to be addressed to ensure pleasing access for residents. A review of the specialist equipment has been carried out; the home is currently considering the report and the registered manager said that any identified shortfalls would be addressed to ensure adequate equipment is in place to meet resident’s needs. There appeared to be a good supply of pressure relieving devices. Communal toilets and bathing facilities are strategically located for ease of access by residents. A walk in shower room and an assisted bathroom have been created on the ground floor. The bathrooms on upper floors require some refurbishment and attention to the clinical appearance of them in order to make bathing a pleasant experience. Bedrooms are located on each of the three floors; they vary in size and layout. Eleven bedrooms have en-suite facilities. There is a rolling programme in place for the redecoration and replacement of soft furnishings of all bedrooms, some have been completed. Bedrooms visited were comfortable and homely, they have been personalised to suit the occupant. The registered manager reported that residents are encouraged to bring personal possessions and items of furniture into the home. All rooms have been fitted with suited door locks and residents are offered a key to increase their privacy. The water supply to the home has been tested. Random hot water checks of all outlets available to residents are carried out and recorded. Any variation in the normal range is acted upon by the maintenance operative. Lighting is domestic in design and bedside lights are supplied to each bedroom. Although the levels of hygiene are satisfactory some bedrooms have a mal odour, which need addressing for the comfort of the occupant and visitors. The registered manager advised that odour control is difficult due to the high ratio of residents with continence problems. The kitchen and laundry rooms were found to be tidy and clean with relevant practices being carried out to prevent infection. Cedar Lodge Nursing Home DS0000063476.V307639.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 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The allocated staff is adequate to meet the needs of the current client group. The home operates a robust recruitment system, which protects residents from harm. Some staff have not received sufficient training for them to be competent to carry out their role. EVIDENCE: The most recent rotas covering four weeks were reviewed. They indicated that sufficient staff are rostered for each shift to care for the numbers and dependency levels of the residents. There is a full complement of ancillary staff and a maintenance operative to ensure that’s staff employed are able to carry out their designated role. It was reported that all trained and care staff are of ethnic minorities whilst the majority of residents are British. The registered manager regularly provides sessions for staff on effective communications. During the fieldwork residents did not raise it as a problem but that the approach of care staff may sometimes be inappropriate. It has been raised as a topic for discussion at residents meetings. A sample of staff files were checked including the latest recruit. The required checks are being carried out including CRB and POVA checks before Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 18 employment is confirmed. The home documents the interviews of each applicant. The arrangements ensure the safety of residents. The home has its own induction checklist, which newly appointed staff are expected to carry out prior to commencement of an in depth induction programme. The pre-inspection questionnaire stated that 50 of care staff have achieved training in NVQ level 2 or above. Some gaps were found in other training that need to be addressed. They include, Moving and Handling, Health and Safety, Food Hygiene, Infection Control and as previously discussed adult protection and Dementia Care. It was noted that further training has been planned that to date regular training has been provided to reduce the gaps identified. Further training that has been carried out to ensure that specialist needs are addressed are Falls, PEG Feeds, Bereavement, Nutrition, Care of Pressure Ulcers, Supervision, Communications and Continence Care. These assist staff in possessing the knowledge and skills to carry their role effectively for the good of residents. All catering staff possess Food Hygiene training certificates to prevent the risk of infection. Two staff were interviewed; they demonstrated adequate knowledge in respect of confidentiality and allegations of abuse. Regular staff meetings are held; the minutes indicate that staff are given ample opportunity to discuss the day to day operations of the home, suggest improvements and to raise concerns. Cedar Lodge Nursing Home DS0000063476.V307639.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, 33, 35, 36, 38 The quality outcome in this area is good. This judgement has been made using the available evidence including a visit to this service. The manager has a clear vision for the home and staff have definitive lines of accountability. The arrangements for quality assurance are comprehensive and include resident’s opinions. The system for handling of resident’s personal finances is not safe. Health and Safety procedures mostly protect residents. EVIDENCE: The registered manager has the knowledge and skills to manage the home and leadership skills to supervise staff and how they deliver care to residents. Information was given that she has commenced training for the Registered Managers Award. She is supported by trained staff and three senior carers. The home operates a good quality assurance system. This includes regular residents and staff questionnaires, monthly audits of medication, the premises, Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 20 equipment and the standard of care planning are carried out. Senior carers also carry out random audits of resident’s appearance and their bedrooms. An annual report is developed that includes audits carried out by external bodies and the contents are shared with residents and staff. Advice was given that any shortfalls found in the care plans are used as a tool for formal staff supervisions. The statement of purpose and service user guide has been produced in large print for the benefit of those who are visually impaired. Information was given that these will also be available in a taped format at a later date for those persons who are unable to read. The process for the safekeeping and financial transactions of resident’s personal monies was examined. The home is not is not ensuring adequate protection; all transactions must include two signatures. There was good documentary evidence of regular and appropriate formal staff supervisions, both parties sign the tool. Information was provided that supervision extends to the ancillary staff. This is viewed as being good practice. All aspects of health and safety checks and servicing are being carried out. The fire alarms are tested and recorded weekly and the emergency lighting monthly. All staff participate in two fire drills a year. The registered manager holds quarterly health and safety meetings. Monthly accident audits are also carried out. These arrangements ensure provision of a safe environment for residents and staff. Cedar Lodge Nursing Home DS0000063476.V307639.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 X 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 2 2 3 X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 3 Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP4 Regulation 18(1)(a) Requirement The registered person must ensure compliance with the homes registration by providing all trained and care staff with training in dementia care. The registered person must ensure that accurately dated comprehensive care plans are developed, which include preferred activities of daily living, life history and background and aspirations to fully meet all needs. The registered person must ensure that all staff receive training in adult protection and challenging behaviour. Timescale of 31/03/06 has not been met. The registered person must carry out further works to provide sufficient communal space and seating to ensure choices are available for all residents. Timescale of 31/08/06 has not been met. The registered person must ensure that the commenced refurbishment works of the DS0000063476.V307639.R01.S.doc Timescale for action 10/12/06 2. OP7 15(1) 31/10/06 3. OP18 13(6) 30/11/06 4. OP20 23(2)(e) 31/03/07 5. OP21 23(2)(j) 31/12/06 Cedar Lodge Nursing Home Version 5.2 Page 23 6. 7. OP26 OP30 16(2)(j,k) 18(1)(a) 8. OP35 13(6) 9. OP38 13(4)(c) bathrooms are completed resulting in an adequate supply of assisted bathing facilities. Timescale of 30/06/06 has been partially met. The registered person must ensure that all rooms are odour free. The registered person must ensure that all staff receive mandatory training, updates and training that has been identified to meet the residents needs. Timescale of 30/04/06 has not been met. The registered person must ensure that two signatures are obtained for all financial transactions of resident’s personal monies. The registered person must replace the cracked overhead pane of glass in the velux window of staff toilet. N.B. Programme is in place to address this. 28/08/06 30/11/06 30/09/06 31/08/06 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 OP9 OP16 Good Practice Recommendations The home is advised to confirm hand written instructions on MAR (medication administration record) charts by two signatures of trained staff. The home is advised to produce and display the complaints procedure in large print for the benefit of persons who are visually impaired. Cedar Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Lodge Nursing Home DS0000063476.V307639.R01.S.doc Version 5.2 Page 25 - 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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