Inspection on 15/12/05 for The Cedars

This inspection was carried out on 15th December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Cedars 17/04/07

The Cedars 16/05/05

The Cedars 03/11/04

The Cedars 22/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Cedars Church Side Methley Leeds West Yorkshire LS26 9BH Lead Inspector Paul Newman Unannounced Inspection 15th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Cedars Address Church Side Methley Leeds West Yorkshire LS26 9BH 01977 512 993 01977 552 806 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) The Cedars Partnership Kathleen B Morgan Care Home 39 Category(ies) of Dementia - over 65 years of age (39), Old age, registration, with number not falling within any other category (39) of places The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2005 Brief Description of the Service: The Cedars is located in the village of Methley near to Castleford but is classed as been in the Leeds area. The home can accommodate up to thirty-nine residents who may have been diagnosed as suffering from Dementia or do not have any specialist needs. Nursing care is not provided but the local healthcare teams support the home. Accommodation is provided in two buildings, the main house has rooms for twenty-six residents and the rest live in the Cottage. An enclosed courtyard provides a safe area for residents to walk and sit in the fresh air. The main house has bedrooms over four floors and some of these are in a modern extension. Access to the upper floors is provided by a passenger lift and a stair lift in addition to the stairs. There are eighteen single and four shared rooms, two of these with ensuite facilities in the main house. The Cottage has nine single rooms, one being ensuite and two double rooms again one with ensuite facilities. Access to all rooms is via the staircase. The home is situated in large attractive gardens. There are plans to extend and change the Cottage in order to increase service provision. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 16 May 2005. There have been no further inspections until this unannounced visit. The people who live in the home prefer the term resident, and this is the term that will be used throughout this report. The purpose of this inspection was to gain an overview of the care, services and facilities provided and also to assess progress in the way the home is dealing with issues that were raised in the last inspection report. During the inspection records were looked at, some parts of the home were seen, such as bedrooms, lounges and bathrooms; care staff were seen carrying out their work; conversations were held with the deputy manager, six members of staff, and nine residents. In addition, a social worker and relatives who were attending a review were spoken with and a community nurse who was attending to a resident. Survey cards were left at the home for residents, relatives or visitors to complete and return to the Commission for Social Care Inspection (CSCI). These cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way will be shared with the provider without revealing the identity of those who replied. The inspection started at 9.30 and lasted for four hours, in addition time was spent preparing for the inspection. Not all National Minimum Standards were inspected during this visit, but over the two inspections all core standards have been inspected at least once. To gain a full picture of how the home meets standards, this report should be read in conjunction with previous reports. What the service does well: What has improved since the last inspection? The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 6 Further improvements have been made to the building. The main house communal areas and corridors have been redecorated and there is an ongoing programme to redecorate bedrooms and replace worn built in wardrobes. New gas fires have been fitted in communal lounges. More staff are expected to complete National Vocational Qualifications (NVQ’s) and by June 2006, 80 of the staff team will have a qualification. This exceeds targets that have been set. A new deputy manager has been appointed who is described by staff as ‘approachable’, ‘organised’ and ‘knows what she is doing’. This gives staff confidence. An activity organiser has been appointed to build on the activities programme already provided. Residents look forward to her visits to the home. 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. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5. Standard 6 does not apply to this home. Pre admission assessments are made that provide clear information about residents care needs. The admission process is good and includes preadmission visits and a full review following a trial period. EVIDENCE: The file of one resident who had recently been admitted was checked. The pre-admission assessment and other supporting documentation that was collated before the resident’s admission provided good information to form the basis of a care plan. By coincidence, this resident’s trial period of six weeks was complete and a review was being held on the day of inspection that included the relatives, social worker, the resident and staff from the home. Before the review started the relatives said that they had visited the home before they made a decision on their father’s behalf for him to live in the home. They felt that the staff had been very helpful in explaining things and had also provided written information. During the trial period staff had kept in communication and they felt welcome when they visited the home. They were confident in the home’s ability to meet the resident’s needs. The social worker equally felt happy with The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 9 the placement and said that the home met the dementia care needs of the resident. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 and 11. Care plans provide staff with clear, and up to date information and guidance to follow. Health care needs are identified and monitored with good support from local health care services. Staff are aware of residents’ needs and treat residents with dignity and respect. Where palliative care is provided, the home treats and cares for families and residents with sensitivity and respect with good support from healthcare professionals. EVIDENCE: Two care plans were checked in detail. One from the main building was for a recent admission, the other in the cottage was for a resident who was terminally ill. The first is referred to in the section above (Choice of Home). The review for this resident was to discuss the trial period and the care plan that had been drawn up so that everyone understood the home’s assessment and agreed the approaches that will be taken in the future. In care homes, it is not always possible to care properly and effectively for residents who are terminally ill. The care plan for the resident in the cottage was clear in the way it documented liaison with the GP, hospitals, community nurses and the Macmillan nursing service. There was good evidence of contact with the family. The verbal accounts of staff working in the cottage The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 11 demonstrated the care and concern they showed for the family as well as the resident. There was no doubt that this resident was being cared for well and with great sensitivity as they came to end of their life. The community nurse who was visiting to treat a resident in the main building said that she felt communication between the home and nursing service was much improved, felt that problems were identified and referred at the right time giving nurses an opportunity to treat problems effectively at an early stage. The general observations and discussions with residents showed that they are cared for by staff who know their care needs and personal preferences and treat them well, with sensitivity and respect. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Social and leisure activities are arranged that residents enjoy and are happy with. Visits from family and friends are encouraged. Residents are supported and encouraged to make choices and decisions about what they do. The food provided is based on traditional meals that residents request and like. EVIDENCE: Since the last inspection an activity organiser has been appointed who comes in for one day a week. By coincidence she was in during the inspection and was continuing to work on the Christmas theme. She is a popular person and the residents look forward to her coming. In addition to this staff provide an activities programme and this includes trips out, entertainers as well as more traditional in-house activities. There are links with the community through the church and some of the residents decorated the church Christmas tree. The visitors spoken with said that staff make them feel welcome and it was clear from what staff and residents were saying that there is a regular flow of visitors throughout the day and evenings. More able residents said that they choose what to wear, the time they get up and go to bed and what they do during the day. Some seem to enjoy chatting with their friends and joining in activities others prefer to spend time in their The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 13 rooms reading, listening to the radio and watching TV. Some have personal telephones that enable then to speak regularly to family and friends. The menus are discussed with residents and they prefer traditional and wholesome English meals and there is a choice each mealtime. The residents consistently said that the food was good, there is plenty of it and it is hot. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 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): 18. Residents have their rights protected and are protected from abuse. EVIDENCE: Since the last inspection the home has referred to adult protection procedures on two occasions. This was in connection with two residents but neither of the concerns were directly associated with the home. Staff did make some sharp and good observations and these warranted the homes intervention and referral to protect the residents. The staffs’ actions demonstrate the existence of good policies and procedures backed up by staff training and awareness. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 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 and 26. The home offers a safe, well-maintained environment for the residents. People are able to personalise their bedrooms. EVIDENCE: The home is decorated and furnished to a good standard throughout and evidence was seen of a regular maintenance programme in place. Since the last inspection the main house, communal areas and corridors have been redecorated and there is an ongoing programme to redecorate bedrooms and replace worn built in wardrobes. New gas fires have been fitted in communal lounges. There is a call system in all areas of the home and alarms are activated to alert staff that people have opened their bedroom doors where they are known to wander. The bedrooms in the main building are of a good size, nicely furnished and made personal by residents bringing their own things with them. Rooms in The Cottage are smaller and there are plans to build an extension and alter this area. All rooms overlook the pleasant garden areas and residents spoken The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 16 to were very happy with their rooms and said that they were very comfortable. They were also able to confirm that staff knock on their doors before entering. There is a lockable space in each room for people to store valuables and money. Rooms can be locked if residents wish and they can hold the key. All doors have two-way locks to ensure entry if there is any emergency. It was good to see that for one resident, who was poorly and unlikely to be able to get down for Christmas festivities, thought had been given and his room had been decorated up for Christmas. The home has a control of infection policy in place and protective clothing is available for staff where required. The laundry assistant holds an NVQ in housekeeping and the machines are capable of washing at high temperatures. The home also has a carpet cleaner for dealing with spills and no offensive odours were present at the time of the inspection. A maintenance person is employed at the home that holds the relevant NVQ. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 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 and 30. The staff are experienced, well trained and know what they are doing. They have good relationships with the residents and care for them well. EVIDENCE: Six members of staff were spoken with during the inspection. They are well organised and there are well established systems of shift handovers that mean information about the residents is up to date. The staff knew each of the residents well and the relationships were good with a lot of warmth and humour. The residents said that staff listen to their views, are friendly, and treat them well. They felt well cared for. There is a training programme and from the records seen and what the staff said, this makes sure that the staffs’ training is up to date and in line with the National Minimum Standards. The staff are committed to training because they know it helps them and they said it makes them feel more confident in their work. Planned training includes infection control, dementia, palliative care and moving and handling. It was noted from what staff had said about fire drills that further drills should be planned to make sure that all have been involved in a recent drill. Further progress has been made with NVQ’s and with those staff currently part way through and expected to complete the home will achieve 805 of the team qualified by June 2006. Throughout the visit it was good to see staff communicating with each other, letting each other know what they were doing and where they would be if needed. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 18 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): 32, 33 and 38. The home is well managed and the interests of the residents are the main concern of the manager and staff. Record keeping for safety checks, maintenance of equipment and systems of communication make sure that the home is a safe place to live. EVIDENCE: Since the last inspection a new deputy manager has been appointed and she assisted in the inspection in the absence of the manager. This appointment has made a positive impact in the home, staff describing the deputy as ‘approachable’, ‘organised’ and ‘knows what she is doing’. This was the impression gained by the way she assisted in the inspection and she will further progress and compliment the good work done by the manager. Staff said that they would welcome more regular staff meetings. The home still continues with regular quality assurance reviews that are carried out by an independent person who every six to eight weeks interviews a cross The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 19 section of residents, staff, relatives and visitors. From the information gathered a summary report is compiled and an action plan developed that reinforces good practice and suggests ideas and actions to make developments that might have been identified. This approach should give people confidence that the home is keen to make sure that the care provided is of a good standard and is prepared to listen to ideas for improvements. The general impression given by residents is that they feel comfortable in raising concerns, that they feel listened to, they feel well cared for, and the atmosphere in the home was warm with lots of good humour. Since the last inspection the Fire Officer has visited and reported that the home meets current fire safety standards. The fire safety records and maintenance checks seen were up to date. The tour of the premises found no obvious health and safety hazards and staff were seen to wear appropriate protective clothing and observe good practices to ensure infection control. Staff training in safe working practices is up to date. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X X X 3 The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 21 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. 1 2 Refer to Standard OP30 OP32 Good Practice Recommendations Further fire drills should be held to make sure that all staff have personally been involved in a recent drill. At the request of staff, management should arrange more regular staff meetings. The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 The Cedars DS0000001621.V270480.R01.S.doc Version 5.0 Page 23 - 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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