Inspection on 22/01/07 for The Cedars

This inspection was carried out on 22nd January 2007.

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

The Cedars 04/09/08

The Cedars 06/11/07

The Cedars 29/11/05

The Cedars 28/07/05

The Cedars 21/02/05

The Cedars 23/08/04

The Cedars 18/03/04

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

CARE HOMES FOR OLDER PEOPLE Cedars (The) High Street Purton Wiltshire SN5 9AF Lead Inspector Alison Duffy Unannounced Inspection 22nd January 2007 09:50 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 Cedars (The) DS0000028140.V325138.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. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedars (The) Address High Street Purton Wiltshire SN5 9AF 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) 01793 772036 01793 772635 The Orders Of St John Care Trust Mrs Michelle Lisa McKeever Care Home 48 Category(ies) of Dementia - over 65 years of age (4), Learning registration, with number disability over 65 years of age (3), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (4), Old age, not falling within any other category (42), Physical disability (8) Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users are only admitted under the category of Physical Disability in order to receive intermediate care within the home’s rehabilitation unit. Service users admitted under the category of Physical Disability must be over 60 years of age. A maximum of eight service users can receive intermediate care in the home at any one time. 29th November 2005 Date of last inspection Brief Description of the Service: The Cedars was built in the 1980s as a purpose built residential home offering accommodation and personal care to residents with a variety of needs. This includes residents over the age of 65 who require care primarily through old age, 3 residents with a learning disability, 4 residents with a mental disorder aged over 65 and or 4 residents diagnosed with dementia. The home can also accommodate up to 8 older people with a physical disability. The home provides 38 places for long term care, 3 for respite care and in the past has offered 8 places for rehabilitation. The rehabilitation unit is not however currently in use. The home also provides day care facilities for up to 15 people. The home is registered to the Orders of St John Care Trust. Mrs Michelle McKeever is the registered manager. Mrs McKeever has been in post for just over a year. The Cedars is situated in the village of Purton and is in close proximity to the various amenities. Residents bedrooms, offering single occupancy are located on the ground and first floor. A passenger lift is in situ. There is a large dining room and adjoining lounge. Additional seating areas have been created within the main entrance and within some areas of the corridors. Staffing levels are maintained at one care leader and five carers in the morning and one care leader and four carers in the evening. At night there are three waking night staff. There are also housekeepers, catering staff, an activities organiser, a maintenance person and an administrator. Designated staff work in the day centre. Fees for living in the home are based on dependency levels and the type of room occupied. The fees range from £395.00 (low standard dependency and a standard room) to £555.00 (very high dependency and a downstairs premier room.) Items such as chiropody, hairdressing, dry cleaning and personal items are not included in the fee. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place initially on the 22nd January 2007 between the hours of 9.50am and 5.20pm. The inspection was concluded on the 6th March 2007 between 10am and 3.10pm. Mrs McKeever was available throughout the inspection and assisted as required. The delay between the two days unfortunately took place because of annual leave and an outbreak of illness within the home. On the first day of the inspection, discussion took place with residents in the communal areas and within the privacy of individual rooms. Discussion also took place with staff when further touring the accommodation. The inspector observed the serving of lunch and viewed care planning information, daily records and assessment material. On the second day of the inspection, staffing information such as training and recruitment documentation was viewed. The medication systems and the safe keeping of residents’ personal monies were also examined. As part of the inspection process, surveys were sent to the home for residents to complete if they wanted to. Comments cards were also distributed to residents’ relatives. Some GPs and care managers were contacted for their views. Feedback was generally positive with comments such as ‘the staff are kind and understanding, they provide a good level of care and the food is very good’ and ‘The Cedars provides a safe and secure atmosphere and a feeling that home is home. This home is a good role model for other establishments.’ Further comments from residents included, ‘everything is fine – I am pleased with it all’ and ‘just to say thank you – I am very comfortable here.’ Additional feedback is reported upon, within the main text of this report. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Residents’ benefit from an environment, which is well maintained, decorated and furnished to a good standard. Attention is given to detail, including pictures and plants within communal areas and corridors. Residents are able to personalise their own room and bring items of furniture with them on admission. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 6 Residents are able to follow their own routines, which include getting up and going to bed when they wish. They are able to choose where they have their meals and whether they join in with the activities organised by the home. Residents’ benefit from an established staff team. Positive relationships between residents and staff were evident. Residents spoke highly of staff and confirmed that they would do small amounts of shopping or make a cup of tea for them in the night. Residents were well groomed and individual rights to privacy and dignity are promoted. Residents have access to health care professionals on a regular basis. A robust recruitment process is in place giving residents additional protection. What has improved since the last inspection? What they could do better: While residents are assessed before their admission to the home, assessment documentation would benefit from greater detail. Documentation should also be signed and dated appropriately. Greater detail is also required within care plans in order to fully reflect individual need. In particular, the management of specific health care conditions must be identified. Instructions from health care professionals, which are currently being documented within residents’ daily records, must also form part of the care plan so that the information is not missed. Assessments regarding the resident’s risk of developing a pressure sore are required. Outcomes and preventative measures, to minimise the risk must be addressed. Staff should ensure that all entries made within resident’s daily notes are factual. Subjective terminology should be avoided. While a number of potential risks are identified, further consideration needs to be given to these aspects within the risk assessment process. All staff must ensure that they accurately follow the medication policies and procedures when administering medication to residents. This includes verifying any unknown change in medication and a new resident’s medication on their Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 7 admission, with a GP. Staff must also sign the medication administration record appropriately. Written instructions would benefit from a counter signatory. The home was generally cleaned to a good standard yet toilets need to be reconsidered within the cleaning schedule, to maintain a satisfactory standard. While it is acknowledged that staffing levels are being addressed, further provision would enable the individuality of residents to be promoted. Many residents appeared satisfied with the level of activity provision available, yet having only 20 hours allocated to activities, for 48 residents restricts the opportunities available. A review of residents’ preferred interests should therefore be undertaken. Following this, the amount of hours required to implement such provision should be recalculated. 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 summary of this inspection report can be made available in other formats on request. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All potential residents are assessed before they are offered a placement within the home. The framework of current assessment documentation however, is restricting and gives insufficient detail, compromising the ability to meet individual, often complex need. EVIDENCE: Mrs McKeever reported that she aims to visit all prospective residents within their own surroundings before admission. In some instances however, distance may be difficult and documentation received from the placing authority and other involved personnel may be relied upon. Mrs McKeever reported that as, the organisation manages other homes in various parts of the country, a home manager in the location of a prospective resident, may be called upon to complete an assessment. This minimises travelling yet ensures the resident would be appropriately placed within a residential care setting. Mrs McKeever reported that all prospective residents are encouraged to visit the home before Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 10 admission. However many are known to the home through their attendance at the day care centre. Within comment cards from residents the majority reported that they received sufficient information about the home before moving in. Some reported a family member had organised the placement. Another reported that their GP had advised residential care. One resident stated ‘as I am a local person it is the right place for me.’ Another said ‘I attended the day centre so it was a natural progression for me to move into the home.’ The assessment documentation of the newest resident was viewed. While it was noted that a number of formats were used, establishing a holistic view of the resident’s needs was a challenge. For example, due to the framework of assessment documentation, key headings restricted the information gained. It was apparent that the individual undertaking the assessment would need to ask additional questions to ensure they received the information required. Due to this and limited spacing, providing sufficient detail to identify need, within the existing format, appeared difficult. Within comment cards, in relation to the question, how can the service improve, one health care professional reported ‘better liaison with referring agencies i.e. hospital/ other GP, social services, when clients are admitted to get full medical history and assess appropriateness of placement.’ Within the file of the newest resident, there was an assessment written by the Community Rehabilitation Team. There were also organisational formats, such as an enquiry sheet, a dependency assessment tool and an admission checklist. The dependency assessment tool contained a tick style format, giving a number, which indicated level of need within specific categories. Detailed information was not available. For example, under the category eyesight, ‘partial vision – impairment with glasses’ was ticked. How this affected the resident’s daily life and the support required was not evident. Within the category anxiety, ‘generally comfortable and accepting’ was documented. It was not clear in what context this part of the assessment had been made. This was particularly evident, as in other assessment documentation anxiety was identified as an area of need. The assessment details on the front page of the care plan identified contact details and a brief health history. However, the information was not signed or dated. There was also a long-term need assessment form. This gave greater detail within some areas, such as support required with personal hygiene. There were occasions however, whereby the form, conflicted with information within the dependency assessment tool. For example, support required with dressing was identified yet within the dependency tool, independence was portrayed. There were some entries of good detail yet some aspects would also benefit from further clarity. Such examples include ‘poor sight’ and ‘has pain relief for XX.’ Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 11 In the past, one unit within the home had been designated as a rehabilitation unit. The contract for the placement of such clients has since been withdrawn. Rehabilitation is therefore no longer provided within the home. Mrs McKeever reported that consideration is currently being given to the future use of the rooms. Once established, an application to vary the home’s registration will be submitted to the CSCI. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of specific conditions, pressure care management and specific risks, need greater focus to ensure individual needs are met. Residents’ benefit from regular access to health care personnel. Staff must adhere to the medication policies and procedures to minimise the risk of error. Staff promote residents’ right to privacy and undertake interactions in a respectful manner. EVIDENCE: All residents have a care plan although not all reflected individual need. The framework gives a long-term need and assessment form and short term care plans. Of those viewed, both documents, gave limited information regarding specific conditions and their management. For example, one long term need and assessment expressed a diagnosis of ‘blind and leg ulcers.’ Further information was not available. Other key aspects such as catheter care and depression were not addressed. The short-term care plan appeared to contain similar formats within all plans. This included matters such as washing, dressing and mobility. Aspects identifying individuality of need were not Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 13 evident. Potential risks to residents such as tissue viability had not been addressed. This was also so in one instance, despite a written entry of a District Nurse highlighting a vulnerable area on a resident. There was no evidence within documentation of any follow up intervention or measures to prevent further deterioration. Within daily notes, an entry stated ‘sore on bottom, sudocreme applied.’ Again, there was no evidence of this within the care plan. There was also no evidence of any intervention to minimise further skin damage or the assessment, which took place agreeing the use of the cream. Contributory factors such, as nutrition had not been assessed yet the staff were monitoring food intake by recording what was eaten. There was no evidence of evaluation or any guidelines for staff, within the resident’s care plan, regarding the time at which, to gain professional health care support. Mrs McKeever reported that the District Nurse regularly visits those residents who may be prone to a pressure sore. There was no information, however detailing how this criterion is reached. While District Nursing input is acknowledged, the responsibility in providing preventative care alongside the District Nurse must be clearly identified. Mrs McKeever was also informed of the need for care staff to clearly record and monitor progress in healing. Initially, staff must therefore describe the detail of the mark or the broken area. This should include matters such as the size, shape, depth, colour and exact positioning. There was some information within the daily records that were not identified within the care plan. This included an instruction from the District Nurse to encourage fluids. Other aspects included ‘need to elevate leg’ and ‘communication giving XX problems.’ Some potential risks were also commented upon within daily records yet were not addressed within the risk assessment process. This included one resident holding their own medication and another not swallowing tablets given to them. Some risk assessments detailed mobility and residents having the door to their room open at night. In these instances control measures needed further detail. Further consideration regarding the risk assessment process is also required. Within daily records it was reported that one resident ‘refused to go to bed.’ There were no guidelines for staff as to how to manage this situation. There were also a number of subjective terms such as ‘very demanding’ and ‘not very cooperative.’ These aspects were discussed with Mrs McKeever with a recommendation that only factual information is documented. In one instance, a member of staff had recorded that it was important for a resident to walk. The member of staff had recorded ‘a firm but fair chat’ within the resident, encouraging this. There was further instruction for staff to encourage such practice. There was no evidence of a formalised health care assessment regarding the resident’s mobility. In such instances, such decisions should not be made by a member of the care staff team, without the basis of an assessment, undertaken by qualified health care personnel. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 14 Within comment cards received from residents, nine reported that they always receive the care they require. Four said usually and one said sometimes. One resident reported ‘staff sometimes lack the knowledge of the physical and mental side effects of my condition.’ Further comments included ‘the staff do all they can for you but time is not always enough for what they would like to do for you’ and ‘of course we are all different, so I find some carers are more tuned to my person needs than others, but I have no complaints.’ Another resident said ‘help is always available.’ A relative reported ‘physical care relating to clothing, washing, hydration and nutrition appears generally good.’ Further relatives’ comments included, ‘individual needs are attended to’ and ‘staff have confidence in communicating with their residents.’ Those residents spoken with reported that they were able to meet with their GP as required. Some spoke of seeing the District Nurse regularly. There was also evidence within residents’ records of specialised services such as the speech and language therapist. Outcomes of these assessments however, should be identified within the individual’s care plan. Residents confirmed that they are able to receive consultations in the privacy of their own room. Within comment cards received from residents, eight stated that they always receive the medical support they require. Six said ‘usually.’ One resident highlighted ‘it depends on the individuals willingness to make their needs known to the doctor at the home. The system has to be made to work.’ Another resident commented ‘the doctors and nurses are very good and helpful.’ Relatives confirmed that information regarding problems or heath issues are usually passed on promptly. One relative reported ‘some care leaders are better than others regarding this. Information given to the home is noted in the daily diary and given to staff at handover time.’ Another relative reported ‘more ability to talk with XX’s lead person would be helpful, but difficult, as her shift patterns rarely coincide with my visits.’ Further comments included ‘every day living problems and health issues are regularly communicated by face to face or telephone conversation’ and ‘I have made a point of wanting to be involved in all issues concerning XX in a constructive way. The staff generally appear to respect this and are helpful.’ Also ‘nothing is ever perfect in this regard but generally my XX appears happy and well cared for. XX is dealt with in a caring and considerate manner.’ A number of health professionals returned surveys and positive feedback was noted. Comments included ‘staff will request specialist advice if there are any concerns or queries’ and ‘staff manage residents’ care with courtesy and understanding.’ A care manager stated ‘The Cedars appears to have a good relationship with the local surgery and district nurse. They work well with them e.g. if a patient has a leg dressing, they will time a shower to accommodate the nurse.’ In relation to maintaining a resident’s privacy and dignity, three health care professionals confirmed, this is always maintained. One said usually. Additional comments included ‘carers are aware of difficulties e.g. if a patient is breathless they will use a wheelchair’ and ‘key workers appear Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 15 knowledgeable about individuals’ care needs and how the service user likes their needs to be met.’ In relation to the question, ‘what does the service do well?’ Comments included ‘good medical care,’ ‘manage increased dependency – both physical and mental – very well’ and ‘all round sympathetic care, appropriate to individual needs, with realistic expectancy of users requirements and requests.’ Medications were securely stored in a locked cupboard and trolleys. A restricted number of staff administer medication. This is undertaken following training and competency checks. A monitored dosage system is used. The system identifies a weekly cycle, but does not state the actual day the medication is to be given. One medication had been introduced in the middle of the cycle. Instead of administering the medication from the accurate point of the cycle, a staff member had used the first tablet. Dates of administration were therefore unclear. This increased the risk of error. There were a number of gaps within the signing of the medication administration record. In one instance, over a four-day period, the records demonstrated that a tablet had been given. A member of staff, later discovered however, that the medication had been unavailable. The resident had not received their medication despite documentation highlighting that it had been given. This gave evidence to suggest that staff had not followed the appropriate procedures. Within the medication administration record, there were a number of handwritten instructions, which had not been countersigned. It was recommended that countersigning written instructions be adopted. Through discussion, the care leader explained that a medication with a different brand name had been delivered. Staff had not checked the medication and it was subsequently given to the resident in addition to their original medication. It was suggested that the pharmacist should be asked to alert staff to any such change. Staff must also verify an unknown change of medication with the GP. Within a daily record it was evident that clarification needed to be gained from a GP regarding a certain medication. This was three days after the resident’s admission. It was evident therefore, that the medication was not checked originally on admission, as per the homes own admission and medication policy. This must form an integral part of the assessment process and be fully recorded. Positive interactions between staff and residents were observed during the inspection. All personal care was undertaken in private and staff were observed to knock before entering residents’ rooms. Residents spoke positively of staff and did not raise any negativity, regarding their rights to privacy and respect. A care manager reported ‘reviews are always held in the service user’s bedroom or the office. I have never observed a resident being addressed inappropriately. Staff make the Cedars homely and seem genuinely fond of the residents.’ Within comment cards received from relatives, there were various positive comments regarding interactions. These included ‘residents are treated as individuals’ and ‘residents are treated with respect.’ Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 16 Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good yet further attention to activity provision would enable residents’ greater opportunity for stimulation and occupation. This judgement has been made using available evidence including a visit to this service. While residents generally appear satisfied with the level of activity provided, the hours deployed to activity provision are minimal. This restricts the ability to address residents’ individual needs both inside the home and within the wider community. Residents are able to follow their preferred routines and receive visitors when they wish. Meal provision is discussed with residents and views are taken into account in order to develop provision. EVIDENCE: Residents reported that they are able to follow their preferred routines and interests. One resident reported that they like to get up very early. They confirmed that when rising, the night staff offer a hot drink. Some residents spoke of spending time quietly in their room either reading, watching television or doing crosswords. Others mentioned activities such as quizzes and bingo. One resident said ‘there’s not much to do. I would like to get out more’ and another said ‘the days seem long. There are beautiful views from the windows, yet there is a limit to how long you can look at them.’ Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 18 Within comment cards received from residents, one said there are always activities in the home, which they can join in with. Five said sometimes and eight said usually. One resident stated ‘much depends on the residents having interests beyond bingo. Cards and dominoes, scrabble, reading, singing and discussion could be encouraged. Often residents are grouped around TV facilities - being elderly, often infirm – they sit and soon fall asleep.’ Another resident stated ‘ I am disabled and can’t take part in many things’ and ‘due to my illness I find it hard to join in with activities, however staff sit with me and keep me company regularly.’ One resident confirmed that they enjoyed a trip to Lechlade in the summer. Another stated ‘I don’t often go down but I could if I wanted to.’ The home has an activities organiser who is designated 20 hours a week for activity provision. These take place over a three-day period yet lunchtimes are an integral part of the hours. On the days when the activities organiser does not work, care staff are responsible for arranging the sessions. The activities organiser reported that understandably, on these occasions, other matters often take priority and the activity does not always take place. The activities organiser showed examples of individual life story work, which had been undertaken with residents. This was positive and much enjoyed. However, opportunities were restricted due to the activity being time consuming. Also, it was acknowledged, that while one-to-one work with a resident was taking place, all the other residents were unoccupied. Activity provision was discussed with Mrs McKeever, who reported that activities do take place yet additional hours would enable greater opportunity. Mrs McKeever reported that regular functions are held with other homes within the organisation and pub trips are also undertaken. These however may appear minimal, as residents sometimes, have to take it in turns to go, due to the demand. Mrs McKeever reported, that it is anticipated with the better weather approaching further external trips can be arranged. The activity organiser also confirmed this and reported that generally, drives and a picnic appear very popular. Within surveys, one health care professional reported ‘as much as possible, within the limitations of a large home, residents are able to choose the way they wish to live their life, yet residents often comment upon lack of activities, other than the popular bingo and visiting entertainers.’ Another reported ‘the home has a very pleasant lounge/dining room and activities are provided. Residents therefore have the choice and are able to socialise or remain in their rooms.’ There were a number of comments from relatives regarding activities. These included ‘The Cedars appears to let people within their limitation live life much, as they wish’ and ‘more activity would be helpful in keeping residents physically active and able, e.g. sitting and standing exercises, use of simple musical instruments and movement to music. Rather a lot of time is spent sitting in chairs at the moment.’ Further comments included, ‘I think the care home does its best regarding entertainment but I feel more variety is required’ Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 19 and ‘a well run integrated day care unit which residents can join in with the activities if they wish.’ Residents confirmed that they are able to have visitors at any time. One resident said ‘they don’t even mind children.’ All reported that their visitors are made to feel welcome. On a tour of the accommodation, Mrs McKeever reported that a computer has recently been set up for residents’ use. Connection to the Internet is anticipated so that residents may e-mail their relatives if they want to do so. One relative confirmed ‘The Cedars is very much a local home with local connections.’ The home has a designated hairdressing room with regular visiting hairdressers. One resident reported that this service was invaluable. There is also a small shop within the home. One resident reported however that their daughter brings in all that they need. Another stated that staff would do any shopping, if they were asked. There is a small fridge available for residents to store any items such as yoghurts. A member of staff also reported that a number of residents have a small fridge in their room. Residents spoke favourably about the meals provided. Comments such as ‘the meals are very good’ and ‘we can’t complain’ were expressed. One resident confirmed that they always have their meals in their room. They said this was accepted as their choice and never questioned. Another resident said that there is always a choice of meal and they are asked what they would like the day before. The menu confirmed the choices available. On the day of the inspection, as the main cook was on annual leave, a care leader was cooking. The lunchtime meal consisted of turkey casserole or cheese and onion pasties. The meal was served according to residents’ preferences and the size of their appetite. Residents were seated, generally at tables of six. On one table there were a number of residents who needed support to eat. One member of staff however, was assisting two residents at the same time. This was discussed with Mrs McKeever, who reported that it had been brought to her attention and would be addressed. Residents confirmed that they had regular drinks throughout the day and could use their call bell if they wanted a hot drink in the night. Within comment cards received from residents, two said they always like the meals, five said usually and five said sometimes. Comments included ‘there is a tendency to rely on potato bake with little flavouring of the potatoes. Marmalade is not always available at breakfast. Sachets of jam etc could be replaced with small amounts of these items placed on the table’ and ‘we have good food but sometimes it is not cooked properly and so much is thrown away.’ Also ‘there is always plenty of food but quite often not well cooked and some are very poor ingredients. Dinner is not always warm. The presentation of some is very poor.’ Further comments included ‘the presentation of food has greatly improved’ and ‘sometimes not very colourful. Sometimes the plates aren’t hot. Sometimes the gravy is late arriving but on the whole it is alright.’ There were two comments stating that the food is ‘very good.’ Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 20 One relative reported that that food is an area that the home could improve upon. It was stated ‘the quality and amount of food provided is a constant source of complaint by many residents.’ Another relative believed there should be greater provision of fresh fruit and fruit juice. A care manager reported ‘I have conducted a number of reviews recently with residents new and established – very happy with care. Most comments were about food – some things are not cooked properly on a regular basis and the lack of daily activities other then bingo and occasions, when they are invited to go into the day centre.’ Mrs McKeever was informed of these aspects and reported that some had already been addressed. Mrs McKeever confirmed further aspects would be discussed with the cook, yet generally she believed, meal provision was of a good standard. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are aware of how to raise any issues and feel their concerns are listened to. Developing a user-friendlier complaints procedure may however benefit, those residents with communication difficulties. While adult protection procedures are in place, information for staff reference should be more readily accessible, enabling residents’ further protection. EVIDENCE: All residents spoken with reported that they would tell a member of staff or Mrs McKeever if they were unhappy. This was confirmed within comment cards. One resident said they would tell their family and they would deal with any problems. A number of residents confirmed that they didn’t feel the need to raise any concerns. They felt sure however, that if they did the staff would sort it out. Within comment cards, two residents stated that they would go to the people in the office. Another said they would ‘tell Sue, the head helper.’ The home’s complaint procedure is displayed on the notice board in the main entrance area. It was recommended that consideration should also be given to a user-friendlier format, so that more residents could benefit from the information. Within comment cards from relatives, all were aware of the home’s complaint procedure. One reported ‘initially I would talk directly to the home manager who is very approachable.’ Another relative confirmed ‘issues raised concerning the security of the home in relation to both residents and Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 22 staff have been raised and addressed successfully.’ A further relative stated ‘the staff are very friendly and open.’ Any incidents within the home have been appropriately referred to the Safeguarding Adults Unit. Mrs McKeever reported that all staff have had adult protection training. Another home manager within the organisation facilitated this. Abuse is also addressed within the organisation’s induction programme and revisited within the NVQ qualification. Mrs McKeever reported that all staff have been given a copy of the ‘No Secrets’ documentation. When asked about adult protection within the home, staff found locating the policies difficult. The ‘No Secrets’ pamphlets were located although it was not possible to identify the contact details of the local Safeguarding Adults Unit. Mrs McKeever was informed of this and subsequently photocopied information for the main office’s notice board. Mrs McKeever also reported that the procedures would be revisited with all staff. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and maintained to a good standard. Residents are able to personalise their own rooms promoting individuality. While the home is generally clean with no unpleasant odours, a review of the procedure for cleaning toilets is required, to minimise the risk of infection. EVIDENCE: The home provides single accommodation to residents, on the ground and first floor. If two residents wish to share, two rooms are converted, to offer a bedroom and a separate sitting room. All residents’ rooms appeared comfortable and individually personalised. Those residents spoken with were happy with their environment. The dining room and various seating areas were furnished to a good standard and well maintained. At the last inspection, a requirement was made to ensure all shower facilities meet the needs of the home. Mrs McKeever explained the Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 24 requirement was made, before she commenced employment. She was not sure therefore what was required, as in her opinion, all showers meet the needs of residents. All are in good working order and accessible to residents. Mrs McKeever reported that one shower is rarely used, as residents prefer to use alternatives within the home. There is also another en-suite shower, which gives access to two residents from their bedrooms. This shower is not used through individual choice. Mrs McKeever confirmed that residents, who have access to the shared en-suite facility, are able to manage the locks appropriately, to ensure privacy. Attention has been given to areas within the corridors, in order to create pleasant seating areas. Mrs McKeever reported that one upstairs corridor is planning to be redecorated. Residents are in the process of choosing the colour scheme. Within one of the bathrooms, there was a patch on the ceiling, which needs repair. Mrs McKeever reported the Trust is very good at maintaining the environment. This year there is allocated work to the roof and the refurbishment of the previous rehabilitation unit. Within comment cards received from residents, eight said that the home is always fresh and clean. Three said usually. One resident confirmed that a very high standard is maintained and another said the standard is ‘excellent.’ Comments from relatives included ‘the home always smells sweet’ and ‘clean and pleasant surroundings.’ Within a tour of the accommodation it was noted that generally the home was clean with no unpleasant odours. There were however a number of toilets, which contained brown marks on the rim of the toilet and the toilet seats. The shortfalls appeared to be in relation to areas in which the domestic staff had not as yet reached, within their route. Mrs McKeever reported that the matter would be discussed with the domestic team and an alternative way of working would be considered, so that each area of the home would receive attention earlier in the day. A number of windows were open during the inspection even though it was a relatively cold day. One resident reported that a member of staff had opened the top window in her room, but she had not been able to close it. This was reported to Mrs McKeever who said she would remind staff of the need to ensure a satisfactory temperature for residents. At the last inspection a requirement was made to ensure all parts of the home are provided with sufficient heating at all times. Mrs McKeever reported that there had been problems with many of the radiator valves. This work has been completed and therefore difficulties have been resolved. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are maintained at a minimal level enabling only residents’ basic needs to be met. A robust recruitment process is in place, which assures residents’ greater protection. Training is given priority yet consideration should be given to enable further training by external providers. EVIDENCE: Staffing levels are generally maintained at five carers and a care leader during the morning shift. In the evening, there are four carers and a care leader. Mrs McKeever reported that on occasions, staffing levels might be slightly higher. In addition to the care staff team, there are housekeeping and catering staff, an administrator, an activities co-ordinator and a maintenance person. Some residents confirmed that staff are very busy. One member of staff reported that residents often confide in the housekeeping staff, as they have more time to talk. Within comment cards received from residents, five stated that staff are always available. Nine said usually. One resident stated ‘they have their duties to organise and perform. This cannot always give individuals the amount of time, individuals would wish, to discuss their problems.’ Another said ‘you ring the bell and they always come to you.’ Concerns with insufficient staffing levels were addressed at the last inspection and a requirement was made to address the shortfall. Mrs McKeever reported that due to commencing employment after the last inspection, she is unaware Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 26 of how the requirement was addressed. Mrs McKeever did report however, that staffing has been addressed in next year’s budget and increases in staffing levels are expected. Within comment cards, twelve residents confirmed that staff always listen and act on what they say. One said, ‘not always’ and another said ‘they listen but sometimes they forget.’ Other comments included ‘the carers are helpful,’ ‘my personal carer is very understanding of the problems I face’ and ‘my carer is very considerate and understands me.’ Also ‘they are very helpful’ and ‘staff are really very good.’ Mrs McKeever reported that the home benefits from a motivated and committed staff team. There are very few staff changes, which has enabled consistency. The recruitment documentation of four staff was viewed. Some of these were employed before Mrs McKeever commenced employment. All files contained an application form, a POVAFirst check, and a CRB disclosure. One file however, only contained one reference. Mrs McKeever explained the reasons for this, yet it was recommended a character reference, should be requested. All contained details of medical fitness, with an application for a night care position, detailing a more detailed health questionnaire. Mrs McKeever and a number of staff reported that training is given high priority and various opportunities are available. Information regarding forthcoming training had been posted on the notice board. Staff reported that unless mandatory, they could ask to participate, if the subject interested them. Mrs McKeever confirmed that tissue viability training has recently been undertaken and all staff have undertaken dementia care training. Mrs McKeever confirmed she assisted with the tissue viability training, due to being a registered nurse. Another home manager also facilitated the training. Mrs McKeever reported that the organisation encourages home managers to develop their expertise, then cascade their knowledge to staff teams. One care leader has undertaken training in infection control and food hygiene, so that they can train other staff. While this is positive, it was also recommended that external trainers should also facilitate training. Within comment cards, one relative reported ‘there are varying degrees of skill apparent amongst the care staff both in physical care and understanding of the needs of people with memory problems and/or dementia.’ Another relative stated, ‘I feel that additional and on going training would be helpful to the staff in understanding the different kinds of dementia and how they affect the lives of people who live with severe memory loss, show aggression and or challenging behaviour. This would enhance staff perception of different kinds of behaviour and enable them to deal with them in a positive manner.’ Other comments included ‘a caring friendly environment provided by long term settled staff’ and ‘staff always appear friendly and kind.’ Also ‘good communication,’ ‘confidence in communicating with their residents’ and ‘friendly to residents, visitors and relatives.’ A further relative stated, in Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 27 relation to improving the service, ‘more training in the understanding of dementia and the behaviours associated with this condition.’ Within feedback from professional health care surveys, it was reported ‘staff have input by ‘specialist’ workers for training shortfalls. They always seek to promote a good service to residents.’ Further comments included, ‘very empathic to residents’ and ‘care staff I have had regular contact with, seem very confident within the limitations of their training/role.’ Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 28 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the benefit of an experienced manager who is resident focused. Various systems are in place to assess service provision and gain residents views. Clear systems are in place to manage residents’ personal monies therefore reducing the risk of error. Health and safety is given priority although further consideration to the documentation of fire safety training would ensure refresher training is easily identified. EVIDENCE: Mrs McKeever has been the registered manager of the home since November 2005. Mrs McKeever is a registered nurse and has varied experience of working with older people within hospital and residential settings. Mrs McKeever has NVQ 4 in management and has also undertaken various short courses since joining the organisation. Mrs McKeever is keen to further develop Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 29 the home and enable a good quality of life for residents. She is positive when speaking of the staff team and believes the standard of care provided is of a good standard. The home has a quality assurance system that is used within all of the homes within the organisation. The system consists of various audits and questionnaires. Mrs McKeever reported that when the questionnaires were last sent out, the response from residents was poor. Mrs McKeever reported that she believes residents prefer to raise issues verbally, as required, rather then filling in forms. In order to encourage a better response, Mrs McKeever is planning to send each resident, a questionnaire before his or her review. The findings will then be discussed during the review forum. As yet, questionnaires to target other stakeholders have not been developed. As part of the home’s quality assurance system, regular residents meetings are held. These were described as positive and actively promote involvement and communication. Other staff, such as the chef are often asked to attend, so that issues can be addressed directly. Residents’ fees are generally paid through standing order. A number of residents have chosen to place small amounts of their personal monies, for the home to hold safely. The systems for managing this were examined. A number of cash amounts were checked against the balance sheets and all were found to correspond. Staff sign and check each transaction. The resident or another member of staff countersigns the record. Receipts were also in place to demonstrate expenditures. The records are regularly audited within the home. External audits also take place. Health and safety is given priority and the organisation has developed significant documentation within this area. There are a large number of policies, procedures and generic risk assessments. At the last inspection a requirement was made to ensure that all required fire safety checks were undertaken and staff received fire instruction. This has been actioned although it was not clear, due to the format of documentation whether all staff had received instruction or when a refresher was due. It was also not apparent, if the newest member of staff had received their instruction. As stated earlier within this report, further attention to the risk assessment process would also be of benefit. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 30 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 Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 31 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 32 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 OP3 Regulation 14 Requirement The registered individuals must ensure that the admission details form is always fully completed and that all sections of residents’ assessments are fully completed and in sufficient detail. The assessment form must also be signed and dated by both the resident and member of staff completing the form. This requirement was identified at the last inspection, yet remains outstanding in part due to insufficient detail and the assessment form not being signed or dated. A revised timescale has therefore been identified. The Registered Person must ensure that the management of specific health care conditions are clearly addressed within the resident’s care plan. At the last inspection a requirement was made to ensure that residents’ care plans are always fully completed and in sufficient detail and that these Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 33 Timescale for action 06/03/07 2 OP7 15 31/05/07 3 OP7 12(1)(a) 4 OP7 13(4)(c) documents are signed and dated by both the resident and the member of staff completing the form. The requirement has not been fully addressed, as in some instances detail remains insufficient. A revised timescale has been identified. The Registered Person must ensure that all residents have their risk of developing a pressure sore assessed. Outcomes and action to be taken must be identified within the resident’s care plan. The registered person must ensure that all potential risks are addressed within the risk assessment process and be regularly reviewed and updated. This was identified at the last inspection. The registered person must ensure that the medication administration record is an accurate reflection of all medication administered. Staff must sign to demonstrate each medication that is given. The registered person must ensure that staff adhere to the organisation’s policies and procedures regarding medication administration. This must include verifying any new medication with a GP and also verifying a new resident’s medication with their own GP before admission. The registered person must ensure that cleaning schedules are revised to ensure that toilets are cleaned to a satisfactory standard. The registered person must ensure that staffing levels are sufficient to meet the individual needs of residents. The CSCI DS0000028140.V325138.R01.S.doc 30/04/07 30/04/07 5 OP9 13(2) 06/03/07 6 OP9 13(2) 06/03/07 7 OP26 13(3) 30/04/07 8 OP27 18(1)(a) 30/04/07 Cedars (The) Version 5.2 Page 34 must be informed when the details of the increased staffing levels are known. This was identified at the last inspection. Additional care hours are expected although they have not, as yet, been implemented. 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 OP7 Good Practice Recommendations The registered person should ensure that all food and fluid charts are evaluated on a regular basis, with clear guidelines on when specialist advice should be gained. This should be documented accordingly. The registered person should ensure that any mark noted on a resident is documented in detail, in order to evidence the healing process. The registered person should ensure that guidelines are available to staff regarding the most efficient ways of managing individual behaviours that challenge. The registered person should ensure that any terms, within documentation, such as ‘very demanding’ or ‘not very cooperative’ are replaced with factual information. The registered person should ensure that any instruction given by a member of the care team is based on a formal assessment by a health care professional. The registered person should ensure that any outcome of a specialised assessment is documented within the resident’s care plan. The registered person should ensure that a member of staff countersigns any hand written medication instruction. The registered person should ensure that a review of activity provision is undertaken in line with residents’ preferred interests. Following this, the amount of hours required to implement such provision should be recalculated. The registered person should ensure that when assisting a resident to eat, they receive the staff member’s full and DS0000028140.V325138.R01.S.doc Version 5.2 Page 35 2 3 4 5 6 7 8 OP7 OP7 OP7 OP7 OP7 OP9 OP12 9 OP15 Cedars (The) 10 11 12 13 14 OP16 OP18 OP30 OP33 OP38 individual attention. The registered person should ensure that the complaints procedure is developed within a user-friendly format. The registered person should ensure that the procedures for reporting an alleged incident are revisited with staff. Information regarding this should be readily accessible. The registered person should ensure that external trainers complement existing training provision, which is facilitated by other home managers and members of the staff team. The registered person should ensure that systems are devised to enable other stakeholders to give their views as part of the home’s quality assurance system. The registered person should ensure that the format to record fire instruction, is revised to clearly identify that all staff have received training. The format should also identify the dates of when refresher training is required. Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Cedars (The) DS0000028140.V325138.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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