CARE HOMES FOR OLDER PEOPLE
The Cedars 23/25 Threshfield Road Baildon Bradford West Yorkshire BD17 6QA Lead Inspector
Ashley Fawthrop Unannounced Inspection 28th February 2006 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 DS0000001304.V283993.R01.S.doc Version 5.1 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 DS0000001304.V283993.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Cedars Address 23/25 Threshfield Road Baildon Bradford West Yorkshire BD17 6QA 01274 531125 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) Mrs Nada Green Mrs Nada Green Care Home 12 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (9), of places Physical disability over 65 years of age (2) The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st October 2005 Brief Description of the Service: The Cedars is a large terrace property situated on the main road approximately half a mile from the centre of Baildon. The home accommodates twelve older people in both single and twin rooms a number have had en-suite facilities added. There is one lounge and dining room on the ground floor which opens out to a decked seating area in an enclosed garden. There are toilets and bathrooms to both floors access to the first floor is by staircase only there is no passenger lift. The home is on a direct bus route between Bradford and Baildon and the rarest bus stop is directly outside the home. The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was undertaken within one day by one inspector. The inspection process consisted of talking with the registered person, staff, service users and visitors where possible. Reading records and observing practices. The registered person was available throughout the inspection and was given feedback on completion. All the standards other than those recorded in this inspection report were inspected at the last visit and were met. The home continues to provide very high standards of care in an excellently maintained and decorated home. The atmosphere is very relaxed and the visitors are made very welcome. The service users are very happy with the levels of care provided by the registered person and the staff. What the service does well: What has improved since the last inspection? The uptake and focus on training continues to improve but the overall high standard remains. The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 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 DS0000001304.V283993.R01.S.doc Version 5.1 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 DS0000001304.V283993.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The contracts for all service users are on file and appropriately record services provided. EVIDENCE: All service users have a contract relating to the care that they receive and services offered on the file. Where the care provided is purchased by Social Services their contract is also on file The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 9 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): 10 Service users are seen to be cared for with respect and their privacy is maintained. EVIDENCE: All staff receive training on induction relating to the principles of care on privacy and dignity. Service users were seen to have the privacy of their own rooms and on speaking to a number were very happy with the level of care they received and they way in which staff assisted with their care. The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 10 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): 15 The meals are nutritional and appealing EVIDENCE: All service users have a nutritional assessment on admission service users said that they are involved in the planning of menus and have a choice in foods. The menus rotate four weekly and there is at least on cooked meal per day, the menus appear to be well balanced and include fresh vegetables and fruit. The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Service users continue to be protected by the complaints and prevention of abuse policies. EVIDENCE: The standards relating to the protection of service users through the complaints system and abuse policies were inspected at the last inspection and were met. The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22 and 26 The standard of decoration and maintenance of the home exceeds the standard required. EVIDENCE: The home is very well maintained both inside and out the sitting area has patio doors that open out onto a decked sitting in a small-enclosed garden. The home is maintained to an excellent standard and the standards of décor and furnishings are good. There are bathrooms and toilets on both floors one of which has been re furnished. Service users bedrooms are individually decorated and furnished giving the feeling of individuality and ownership. There are dedicated cleaning staff employed and the home is clean and free from odours. The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Service users continue to be protected by the procedures for recruiting and training staff. EVIDENCE: All the standards were inspected at the last inspection and were met there have been no changes to staff recruitment policies since that time, training continues to be ongoing and staff turn over remains low. The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 14 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): 38 Service users and staff live and work in a safe environment. EVIDENCE: The are health and safety policies that relate to the moving and handling of service users and objects, for the storage of substances under COSHH as well as infection control and fire safety. The home is maintained by the husband of the registered person who has the relevant skills to ensure this is done safely. The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 4 X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 16 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. Refer to Standard Good Practice Recommendations The Cedars DS0000001304.V283993.R01.S.doc Version 5.1 Page 17 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
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