Inspection on 20/11/06 for The Cedars and Larches Care Home

This inspection was carried out on 20th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 and Larches Care Home 23/10/07

The Cedars and Larches Care Home 28/02/06

The Cedars and Larches Care Home 18/07/05

The Cedars and Larches Care Home 27/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Cedars and Larches Care Home 16 Queens Drive Ilkeston Derbyshire DE7 5GR Lead Inspector Steve Smith Key Unannounced Inspection 20th November 2006 11:20 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 and Larches Care Home DS0000002129.V316245.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. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars and Larches Care Home Address 16 Queens Drive Ilkeston Derbyshire DE7 5GR 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) 0115 9440166 Exceler Healthcare Services Limited Mrs Janina Ann Wright Care Home 69 Category(ies) of Old age, not falling within any other category registration, with number (69) of places The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The Cedars and Larches Care Home is registered to provide personal care with nursing to male and female service users who fall within the following categories: Old age, not falling within any other category (OP) 69 may be admitted to The Cedars and Larches Care Home The Cedars and Larches Care Home may accommodate the person of category LP/PD named in the variation letter dated 3rd August 2005. The Cedars and Larches Care Home may accommodate the person of category DE(E) named in variation application V34857. The maximum number of persons to be accommodated at the Cedars and Larches Care Home is 69. 28th February 2006 Date of last inspection Brief Description of the Service: The Cedars and Larches is registered to provide nursing and personal care for up to 69 Residents over the age of 65. The Home is situated close to the centre of the town of Ilkeston, in a quiet but accessible location. The Home is on one site, but in two distinct wings, all but joined in the middle. One wing is called The Cedars and provides residential care, and The Larches provides nursing care. Each wing is very similar, although The Larches has wider corridors, due to providing a nursing service. Each wing provides a main lounge and dining area on the ground floor, with smaller lounges on the first floor. The Home also has one passenger lift and staircase in each wing, providing access to the first floor facilities. In the main, the Home provides single bedrooms, although a small number of double bedrooms are available. No ensuite facilities are provided, but there are sufficient toilet and hygiene facilities available throughout the Home. All bedrooms are equipped with a link to the call system. Residents are encouraged to personalise their bedrooms with small items of furniture and mementoes, if they so wish. Support services are in place, with a choice of General Practitioners, and chiropody, dental, optician and other services arranged as appropriate. A visiting hairdressing service is provided. An Activities Coordinator is employed, throughout five days of the week. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 5 There is a gardened area beside the home, which has been designed to be accessible to all Residents. The Home has open visiting arrangements. The charges made for a room at The Cedars and Larches range from £298.20 to £533.00 a week. These charges are dependent on the size of room, the facilities provided, whether the room is a double or single room, and whether residential or nursing care in required. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just under 5.25 hours. Discussion was held with two Residents, whose records were also ‘case tracked’, the Manager of the Home, and one member of the care team. A number of records were examined, and a number of the Residents bedrooms and all public areas of the Home were examined. The Commission’s pre-inspection questionnaire, sent to the Manager, was examined. Although the Commission’s questionnaire was sent to a selection of Residents, none had been returned at the time of this inspection. What the service does well: What has improved since the last inspection? The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 7 The last inspection took place in February 2006, and four Requirements set at that time had been met. Medication issues needed to be addressed in both The Cedars and Larches sections of the Home. These had been addressed to good effect in The Cedars section. Combustible items previously found under staircase areas of the Home had been removed and were not present at this inspection. Lockable facilities had been provided, in The Larches section of the Home, for Residents to put away valuable items. Staff had been trained to meet First Aid issues that might arise in the Home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Cedars and Larches Care Home DS0000002129.V316245.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 The Cedars and Larches Care Home DS0000002129.V316245.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): Standards 1 & 3. The quality in this outcome area was Good. This judgement had been made using available evidence including a visit to the service. The Registered Providers statement of purpose and Residents Guide were satisfactorily completed, although recent updates to the Residents Guide needed to be included, to ensure that prospective residents would be adequately informed of the operation of the Home prior to deciding to move there. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers statement of purpose was examined and found to be appropriately completed, as was the Residents Guide. In September 2006, the details to be included within the Resident’s Guide where significantly updated by the government, but the Manager said that she had not been unaware of this change, and so the Guide was awaiting the necessary updates. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 10 When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident. If the Resident was self-funding from the outset, the Manager completed her own summary of needs, which were seen during the inspection. As a result of these two assessments, Residents’ needs would be appropriately met in the home. Standard 6 does not apply to this Home. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Adequate. This judgement had been made using available evidence including a visit to this service. Residents’ health and personal care needs were being met, as demonstrated within care plans. However, safe medication procedures needed to be updated to ensure that Residents health care needs were always met. In addition, Residents were not always treated with privacy and dignity, which may affect their well-being. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. Copies of the initial assessment completed by the Social Services Care Manager, where one was involved, were available, and the staff in the Home had completed their own initial assessment of needs for each of the four Residents. There were also good detailed care plans and risk assessments available in each record examined, providing staff with information to meet Residents needs. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 12 However, the Manager had not ensured that Residents’ possible limitations of choice, freedom and decision-making abilities, if they were suffering from dementia, were formally recorded and reviewed at regular intervals. The files showed that records of events affecting each Resident were kept. However, no record of the formal reviews of care could be found in any of the files, which included reviews carried out by the Derbyshire Social Services Dept or reviews carried out by the Manager of the Home. The Commission recommends that these reviews should be carried out on at least a six monthly basis, and should be signed by each Resident, where they were able. However, where Residents were judged unable to sign their records, the Manager needed to decide with relatives which relative should act as the Resident’s ‘representative’ and to sign the record as such. Residents’ records were easy to read, with regular entries being made. The files were well organised, with different sections, and they were securely stored. Each file contained a confidential section, as necessary. However, there was no evidence to show that the Manager reviewed the files on a regular basis. Within the daily record of events in one of the files, a nurse was found to ask other staff to monitor the condition of the Resident – ‘Please observe’. However, subsequent entries in the records did not refer to this request, so it was not possible to see any outcome of the request to ‘Please observe’. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents were examined. A good system was found to be in use in The Cedars section of the Home, but in The Larches section a number of issues needed attention: 1. The Medication Administration Record (MAR) sheet for one Resident had been altered by staff of the Home from a required medication to an ‘as necessary’ (PRN) medication, but with no indication as to who had authorised the change. A further four entries on MAR sheets had been re-written by staff, supported by two signatures, but they did not state which Doctor had authorised the change, nor the date on which the change was to take place. 2. One nurse was found to be using a signature on the MAR sheet that corresponded to a notation provided at the bottom of the MAR sheet. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 13 3. On a number of MAR sheets it stated that medication was to be taken 3 times a daily, but staff in the Home had only provided the medication twice a day. There were also gaps in provision of some of this medication, suggesting that it was being provided on a PRN basis only. 4. When a medication had been refused by a Resident staff indicated this by using an ‘X’ or ‘0’ or an ‘R’. They did not use the notation provided at the foot of the MAR sheet. 5. When some MAR sheets was compared with the blister packs, containing the medication, it was found that they did not correspond, as staff were not consistently signing the MAR sheets. On some occasions medication was found in the blister packs but staff had signed the MAR sheet to say the medication had been taken. 6. On at least 4 MAR sheets the start date differed from the other MAR sheets, therefore signatures by staff distributing the medication were required in different places on these MAR sheets. The MAR sheets should all require signing in the same place. This helps to ensure that all medications are given out correctly, and enables the Manager to easily check that this had been done correctly. Two Residents were spoken to about life in the Home. They both said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘They all know what to do, they are very good .’ ‘Yes, they always do it my way.’ ‘I’m much safer here than being in my own home.’ However, during the mealtime observed, a member of staff was heard to call out ‘Any of you self-feeders need a pudding’ which was obviously inappropriate. This same member of staff was heard to say to a Resident that she could not remember their name. When she was told the name the member of staff repeatedly made fun of the name, which the Resident did not join in with. Again, this same member of staff was asked by a Resident whom I, the Inspector, was. The Resident was told I was a new Resident, as a joke, but the Resident was not told this, and the joke was kept running with other Residents, who were also not told of the joke. Therefore the joke was enjoyed by the member of staff and not by the Residents. Throughout the time spent in the Home, staff were heard to call Residents ‘sweetheart’, ‘darling’ and ‘good girl’. However, outside of residential care older people are not called by these names by people much younger than themselves. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 14 Residents were also asked about their wishes following their death at the Home. One said that she didn’t think that anyone had discussed this with her. However, the second Resident said that she was given a form to fill in about this on arrival at the Home, and she was helped to complete it by her son. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 & 15. The quality in this outcome area was Good. This judgement had been made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, and Residents were given a wholesome and appealing diet in pleasant surroundings, that enhance Residents well being. EVIDENCE: Two of the Residents were asked about the activities provided in the Home. Both spoke of playing bingo, and that Residents could be taken out to the local shops by the Activities Coordinator. One said that some Residents had been taken out to the local fair, that had been in the town the previous week. The other said that the Activities Coordinator attended the Home 5 days each week. The Manager later confirmed that the Activities Coordinator visited the Home Monday to Friday, throughout each day, each week. Both Residents said that they decided when they got up and went to bed – ‘I get up when I am ready and go to bed when I like.’ ‘I decide when I get up and go to bed. I like to stay in my room.’ Both male and female staff were seen to be on duty. One Resident said that she could be cared for by a female member of staff if she chose, ‘…but all staff are very good and so I am not really worried.’ The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 16 One Resident said that she had been out to the shops with the Activities Coordinator, and the second said ‘the Activities lady asked me last week if I would like to go out, but I said no because I had been out with my family.’ One Resident said that a minister came to the Home and provided services. This Resident also said that she had a postal vote and so was able to take part in elections, both nationally and locally. Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘We always meet in my bedroom in private.’ One resident said that when staff need to see her in her room they knock, and ‘… I call and say who is it and they open the door and come in.’ However, the second said that ‘Staff just knock and open the door, they don’t wait for me to say ‘come in’’. Residents said that their mail was always delivered unopened, and that the Home was a ‘non-smoking’ home. The Residents said that meals were always good - ‘A choice is always offered’. ‘They now have a menu on the table and you can pick what you want. (They have) just started that last week.’ Staff were heard explaining the menu to Residents, to obtain their choice. Staff and the Manager confirmed that a choice was always offered at all meals provided by the Home. A member of staff was observed talking to a Resident while assisting with that Resident’s meal, despite the fact that the Resident was unable to speak. This was seen as good practice. Staff were also observed attending to the needs of each Resident with their meal from start to finish, before assisting another Resident. Again, this was seen as good practice. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 17 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): Standards 16 & 18. The quality in this outcome area was good. This judgement had been made using available evidence including a visit to this service. The record of complaints and concerns made to the Registered Providers or Manager needed to be improved to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: One of the Residents said that if they had a complaint to make they ‘would tell Nina (the Manager), she is the best there is, really marvellous’, and the complaint would be investigated. The other Resident said that she would tell senior member of staff on duty. However, neither of them said that they had had to do this. The Commission had not received any notice of complaint since the last inspection of the Home in February 2006. Good procedures and records were maintained of written complaints. Since the last inspection three written complaints had been made to the Manager. These were seen and had been satisfactorily resolved. However, there was no record of verbal complaints being made, despite the fact that the majority of complaints would be made verbally to a senior member of staff. The Registered Providers’ complaints procedure detailed that all complaints would be responded to by a representative of the Registered Providers or the Manager within at least 28 days. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 18 The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. There were also copies of the Public Interest Disclosure Act of 1998 and the Dept of Health’s policy called ‘No Secrets’ available in the Home. It was confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Provider ensured that all staff understood physical and verbal aggression by Residents. The Manager also said that a policy was available to staff stating that they could not benefit from Residents wills. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 19 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): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement had been made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the Home, which included a sample of the bedrooms of the Residents. The Home was appropriately decorated throughout, and the lounges and dining rooms were attractive, pleasant to sit in, and were provided with the appropriate items for the Residents. The bedrooms seen provided satisfactory space and provision for each Resident. The gardens were also well laid out and looked most welcoming. Apart from the two large lounges, small lounges were available throughout the Home. The Registered Providers had provided appropriate furnishings in all locations seen during the inspection. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 20 Toilets were clearly marked and were easily available to all Residents. A call system was available throughout the Home. All bedroom doors were provided with locks and a lockable facility was available within each bedroom. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities throughout, and laundry was washed at appropriate temperatures. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 21 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): Standards The quality in this outcome area was Good. This judgement had been made using available evidence including a visit to this service. Nursing and care staffing was provided to meet the needs of Residents. However, the Manager needed to ensure that appropriate recruitment practices were always followed, when employing new members of staff, to safeguard Residents welfare. EVIDENCE: Staffing provided in each section of the Home were calculated in isolation one from the other. Residents in the nursing section and residential section said that they were happy with the staffing provided, as did the member of staff spoken to. At the time of this inspection it was found that more than 50 of care staff had a qualification of at least NVQ level 2 in Care, and therefore met the expectation of the Commission. The records of two new staff employed during the past 11 months were examined to see whether the Manager had obtained all relevant information about them. It was found that almost all information had been obtained. However, she had not obtained a full history of employment, dating back to when the new members of staff had left school. This information is required to allow the Manager to follow up the reasons for leaving any other care establishment, in case the person was dismissed as a result of inappropriate The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 22 behaviour towards Residents. The records of one member of staff also lacked a photograph. All other records were satisfactory. Staff induction and foundation training was provided for all new staff that came to work in the Home. The Manager also said that all care and nursing staff were provided with at least three paid days training a year. Records of all of this training were seen. All staff also had an individual training and development assessment and profile. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35 & 38. The quality in this outcome area was Good. This judgement had been made using available evidence including a visit to this service. The Manager had provided Quality Assurance issues to ensure Residents care was maintained at a positive standard. Staff also received regular training to ensure that Residents needs were always met. EVIDENCE: The Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management. The records of the monthly ‘inspections’ of the Home, carried out by a representative of the Registered Providers, were examined and found to be in good order. Resident care was therefore regularly checked by the Registered Providers. An annual development plan for the operation of the Home was provided, and Residents’, relatives and other professional’s surveys had been carried out, and The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 24 the results published. Individual and group discussion took place between the Residents and the Manager, concerning life in the Home. Therefore, the Manager was meeting the Quality Assurance standards set for the Home. The Manager was able to show that the personal money of Residents was maintained satisfactorily. The training required by the Regulations was examined. This showed that Moving and Handling training, Fire training, First Aid training, Food Hygiene training and Infection Control training were all up to date. In addition, the Manager was able to show that training was also provided on Incontinence, Tissue Viability, Palliative Care, Dementia and Visual Impairment. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Registered Providers had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Manager was able to show that she had provided risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff, and had provided a written statement of the policy, organisation and arrangements for maintaining these safe working practices in the Home. The Manager was also able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 25 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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP1 Regulation 5 Requirement The Registered Providers and Manager need to review the Residents Guide and update it in line with the legal changes that came into force in September 2006. The Medication Administration Record (MAR) sheet can only be altered with the authority of a Doctor. This must be indicated on the MAR sheet by stating the name of the Doctor, the date of the changed and be signed by two staff with authority to distribute medication. The nurse using a signature that reproduced a notation from the bottom of each MAR sheet must sign the MAR sheet in a different manner. Medication must be distributed to Residents as detailed on the MAR sheets on all occasions. Staff must use the notation provided at the foot of all MAR sheets whenever necessary. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 27 Timescale for action 15/01/07 2. OP9 13 & 17 Sch 3 15/01/07 Whenever staff give medication to Residents they must sign the MAR sheet. The notation provided at the bottom of each MAR sheet must be used if medication is not taken. 3. OP10 12 All staff must be instructed during their induction on how to treat Residents with respected at all times. 15/01/07 4. OP16 22 & 17 The Manager must ensure that a Sch 4, 11. record is maintained of all verbal complaints made, as well as written complaints. 19 The Registered Providers and Manager must check, and hold documentary evidence, that all new staff employed have satisfied the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, amended in 2004. 15/01/07 5. OP29 15/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP7 No. 1. Good Practice Recommendations Each Resident suffering with dementia, or their representative, should have the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome needs to be recorded in each Resident’s records, at least on a 6 monthly basis. The Manager needs to complete formal 6 monthly reviews of care with Residents. Those attending the review should include the Resident, their relatives and representative, The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 28 and staff from the home. Where Social Services Depts carry out annual reviews of care this could be one of the 6 monthly reviews. When nursing staff use the Resident’s record of events to ask other staff to carry out tasks, such as ‘Please observe’, the task should be addressed on each entry following until the staff member requesting the task signs it off as no longer needed. 2. 3. OP9 OP12 The Medication Administration Record sheets should all start and finish on the same date. Staff should be made aware of those Residents who should be encouraged, following staff knocking on their bedroom door, to invite staff into their bedrooms and those Residents who can no longer do this. The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 The Cedars and Larches Care Home DS0000002129.V316245.R01.S.doc Version 5.2 Page 30 - 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. 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