Inspection on 16/05/05 for The Cedars

This inspection was carried out on 16th May 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 15/12/05

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 LS26 9BH Lead Inspector Kathleen Firth Unannounced 10.15am 16 May 2005 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. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Cedars Address Church Lane Methley Leeds LS26 9BH 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) 01977 512993 01977 552806 The Cedars Partnership Kathleen Morgan Care home 39 Category(ies) of Old age (39) Dementia - over 65 (39) registration, with number of places The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 02.11.2004 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 home is supported by the local healthcare teams. 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 been ensuite and two double rooms again one with ensiute 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 J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 6.75 hours by one inspector on Monday May 16th, 2005. The inspector toured the building, spoke with residents, staff, management and visitors, examined residents’ records including care plans, menus, staff rosters and the Service User Guide. Staff, residents and visitors were very helpful throughout the inspection and were happy to join in the process. Eleven residents, five staff members, the manager plus two relatives who were present on the day were all spoken to. What the service does well: What has improved since the last inspection? Care plans are reviewed on a regular basis and this is clearly recorded. Changes made to the care plans are discussed with residents and /or their relatives. The key worker system has been developed further. Regular staff supervision sessions are now in place. All staff are working on or have achieved an NVQ. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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 standard(s) 1, 3, 4,5 People are able to make an informed decision about the home from the written information they receive and what they see when they visit the home. EVIDENCE: A copy of the Service user guide given to all prospective residents was seen, and found to be very comprehensive, containing sufficient information to enable the person to make an informed choice about the home. The pre and admission assessments were in the resident’s files and were seen to be very comprehensive. They contained sufficient information for staff to know what the needs of the people were and if these could be met at the home. Social work assessments were present in the files and any possible risk assessments had been completed. All prospective residents are invited to visit the home prior to admission and some residents spoken to confirmed that they had done so, and where this was not possible their relatives had. The manager said that social workers or an advocate is invited to visit if the resident does not have any relatives. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 9 The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 Staff are aware of the residents’ needs and there is good communication amongst the staff group. Residents are treated with dignity and their privacy maintained at all times. EVIDENCE: Care plans looked at contained the needs of the residents and what tasks were required to be done in order for staff to meet these needs. The plans were clear, concise, easily understood and contained healthcare, social and religious needs. Any allergies were recorded on the care plans, as were any special instructions. Risk assessments alongside coping strategies were in place as appropriate. Evidence was seen that the care plans are reviewed and updated on a regular basis. Residents said that they are treated with respect and staff maintain their dignity whilst meeting their needs. GP and district nurses’ visits are recorded along with the reason for the visit and any action required following the visit. Evidence was in the residents’ files that systems are in place to ensure regular visits by dentists, opticians and chiropodists. Relatives are informed when a GP has visited and given the appropriate feedback. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 11 The home has a good medication policy and procedure in place. Medication was seen to be stored correctly and all records were appropriately maintained. The residents’ photographs are inside the medication file and any possible side effects from particular medicine are recorded. Different coloured packs are used for medications administered at different times of the day. The pharmacist signs and stamps the records made of any medicines returned to the chemist. Staff were seen to give out medication in a correct manner. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15 Residents are encouraged to be part of the decision making process and make choices about their lifestyle. They are supported to maintain contact with family and friends and visitors are welcomed at the home. A good, varied and nutritious diet taking into account individual choices is provided at the home. EVIDENCE: People spoken to said that they feel able to voice any ideas they may have particularly about activities and meals and that these are listened to. Residents are free to come and go as they wish providing this is all recorded in the care plan. People spoken to confirmed that they can go to bed/get up at times of their choice and their visitors are welcomed at any time. Relatives visiting said that they are always made to feel welcome and that they are able to talk to the manager and staff at all times. Evidence was heard of the manger giving a daughter information about a doctor’s visit. There is a designated area for smoking in the home. Staff supervise residents who are unable to smoke safely. Residents spoken to confirmed that the meals at the home are very good and that they enjoy them. People can eat in their room if this is their choice and the dining areas in the home are very pleasant and comfortable. One person said she was bored with sandwiches at tea-time but the manager said that there is an alternative offered. The menus confirmed two choices are always The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 13 available and that individual likes/dislikes are taken into account. The meal served at the time of the inspection was nutritious in content and well presented. Staff were seen to offer residents appropriate help to ensure they were able to enjoy their meal. Nutritional risk assessments are done where they are required and regular weight checks are done and recorded. There are some activities at the home and residents said they were looking forward to an imminent trip to the coast. The manager said that there are plans to appoint an activities organiser. Some residents said that they are quite happy entertaining themselves but others said they enjoy organised activities. Residents’ likes/dislikes concerning activities are recorded in their care plan. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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 standard(s) 16, 17,18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents have their rights protected and are protected from abuse. EVIDENCE: The appropriate policies and procedures were seen to be in place and the manager confirmed that staff have had Adult Protection training. Staff receive a copy of the Adult protection policy once they have completed the training. They are all aware of what to do if any complaint was made although none have been received in the past twelve months. The complaints procedure is printed in the Service User Guide so all residents and their family/friends have easy access to this. Residents and relatives spoken to confirmed that they feel able to speak to staff if there is anything they are unhappy about and that is dealt with quickly and appropriately. Residents confirmed that they are able to vote and that staff give any help required to confirm that it is done correctly. Some people used the postal system in the recent election and those who wanted to go were taken to the polling station. The home informs residents that they or their representatives can have access to their records. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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 standard(s) 19, 21, 24, 26 The home offers a safe, well-maintained environment for the residents and provides appropriate bathing and toilet facilities. EVIDENCE: The home is decorated and furnished to a good standard throughout and evidence was seen of a regular maintenance programme in place. 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 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. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 16 There were sufficient toilets near to the communal rooms to ensure residents easy access. They are all big enough to allow people easy access if using a walking aid or wheelchair. Soap and towels were available in all of the toilets and the water was at the correct temperature. Assisted bathing facilities are available at the home. No hazards were seen that could cause problems for residents, visitors or staff. 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 urine 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 J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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, 30 Residents are supported and protected by recruitment procedures in place. Staffing numbers and skills ensure that the residents’ needs can be met. EVIDENCE: The staff numbers were appropriate at the time of the inspection and residents and staff were able to confirm that this is the normal way of working. The staff rosters viewed for a period of weeks confirmed the numbers and grades of staff on duty. The manager said that she can access extra staff if they are required. Recruitment is carried out to comply with equal opportunities and two written references plus CRB checks are required before staff begin work. Staff files were seen to contain the necessary checks other than in one instance. The administrator instigated an investigation into how this had occurred immediately it was brought to her notice. Training takes a high priority and staff spoken to said that they were able to access any relevant courses. All of the staff are encouraged to do NVQ and everyone at the home has completed or is working on an award. The manager confirmed that staff receive training in Adult Protection, Data protection, and health and safety training. Regular staff meetings are held with minutes made available. Talking to staff there appeared to be a clear understanding of each other’s roles and responsibilities and clear lines of accountability. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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 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, 38 The home is well managed, the interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager has many years of experience working in residential care for older people and has recently completed the registered manager’s award. She holds regular residents’ meetings and is open to any ideas and suggestions put forward at these. Residents confirmed this, as did the visitors spoken to. Staff all said that she offers them excellent support and is happy to speak to them if they have any concerns/ideas. Financial transactions carried out on behalf of residents were all seen to be correctly maintained and up to date. There is an awareness of health and safety at the home and all staff receive training in this area. Hoists and other moving aids are available for staff to use when moving residents. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 19 The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 x 3 x x 3 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 3 3 3 x 3 x 3 x x 3 The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 21 NO 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 Regulation Requirement There are no requirenets arising from this inspection. 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. Refer to Standard 29 Good Practice Recommendations All relevent documentation should be in Staff files. The Cedars J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley 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 J52 S1621 The Cedars V226940 160505 Stage 4.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!