Inspection on 01/02/07 for The Cedars Nursing Home

This inspection was carried out on 1st February 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 Nursing Home 04/02/09

The Cedars Nursing Home 25/02/08

The Cedars Nursing Home 06/10/05

The Cedars Nursing Home 18/07/05

The Cedars Nursing Home 03/05/05

The Cedars Nursing Home 03/02/05

The Cedars Nursing Home 30/09/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Cedars Nursing Home Cedar Rd. Balby Doncaster South Yorkshire DN4 9HU Lead Inspector Janet McBride and Val Hoyle Key Unannounced Inspection 1st February 2007 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 Nursing Home DS0000015852.V312296.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 Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars Nursing Home Address Cedar Rd. Balby Doncaster South Yorkshire DN4 9HU 01302 310668 01302 310852 NONE www.fshc.co.uk Four Seasons Health Care (England) Limited (wholly owned subsidiary of Four Seasons Health Care Ltd) ** Post Vacant *** Care Home 66 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) Category(ies) of Old age, not falling within any other category registration, with number (66) of places The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named client under the age of 65 years will be allowed to remain in the home. This condition will cease to apply when the client leaves the home. For the home to be able to admit up to three service users aged 60 65 within the category of registration 6th October 2005 Date of last inspection Brief Description of the Service: The Cedars is a care home located in Balby Doncaster it is set in a residential area with shops and amenities nearby. It is comprised of two units. The units accommodate up to 66 service users over the age of 65. One unit accommodates service users that require nursing care and the other unit accommodates service users requiring personal care. Both units are on two floors accessed by stairs and a passenger lift. There is one kitchen and laundry for both units. Fees range from Residential Care £ 375:00 per week, Nursing Care £553:00, as of February 2007 additional charges are made for hairdressing, Chiropody, Optical, Dental services and magazines. For further information contact the home. Information about the service is available to service users and their families via the home’s Statement of Purpose and the Service User Guide. The last inspection report was available on request from the manager. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this Key Unannounced Inspection, which took place on the 1st of February 2007 for 8 hours. A random inspection was carried out on the 22nd June 2006. The reason for this visit was to assess the standards of care. The home is registered for 66 beds, at the time of inspection 53 residents were residing in the home. Pre-inspection work was carried out for example, analysis of statutory notifications, complaints and all other relevant documentation. During the inspection documentation and records were examined for example, medication, complaints, accident records, staff rotas, staff training files. Case tracking of three residents care plans took place, which were crossreferenced with other relevant documentation for those residents. The inspection included a tour of the premises and direct observation of staff interaction with residents throughout the visit. Information was gathered from as many different individuals as possible that had contact with the residents, including individual interviews with members of staff, including the manager, residents and feedback from relatives and visitors. Talking to some of the residents within the home and feedback from relatives and visitors on the day. Twenty comment cards were sent out to residents prior the inspection and eight were received back their comments are included in the report. The inspectors would like to thank all the staff and residents for their cooperation in the inspection process. Verbal feedback was given to the manager at the end of the inspection, two immediate requirements were given to the home relating to health and safety. What the service does well: A number of service users said they were happy with the home and the care provided by staff, they also said staff worked really hard to make it a nice place to live. Service users can participate in community activities if they wish for example by voting in elections either by post or by visiting a polling station. Service users and relatives are provided with information to enable them to raise concerns or complaints about the home and the care provided. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 6 Information about local advocacy services is available and can be used for any service users who require assistance in exercising their rights and don’t have any relatives or friends for support. What has improved since the last inspection? 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 Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 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 Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6. Quality in this outcome area is Good. This judgement has been made using the available evidence in records, interviewing staff, residents and visitors on the day. Service users were fully assessed prior to moving into the home, with other professionals involved if needed, this ensured that service users care needs were met, by staff who had the skills to deliver the appropriate care. EVIDENCE: Records showed that service users had a full needs assessment prior to being admitted to the home, this ensured that the home could meet their needs, and any specialised needs were catered for as required. Care staff continue to undertake statutory training and NVQ training as a means of ensuring that the home can meet the service users needs. Discussions with service users and families confirmed that the home welcomes visits before admission to assess the quality, facilities and suitability of the home. The home offers residential and nursing care but does not offer intermediate care. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 9 The home had conditions to their registration these were checked and remain applicable for their registration certificate. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is Adequate. The judgement has been made using available evidence including a visit to this service, including examination of documents and discussion with staff and visitors to the home. The care plans provide staff with sufficient information to meet the needs of service users. Service users health issues are met by staff at the home, with support from health professionals. Medication policies and procedures are well managed. Staff have the necessary skills to administer medication to service users, ensuring their safety and protection. EVIDENCE: Three care plans were case tracked and cross-referenced with medication and other relevant documentation relating to that service user. The care plans on both units provided adequate information to support the needs of the service users. However there was gaps in the monitoring of healthcare needs. One example of this was where a service user had suffered from depression in the past, but there was no evidence that this was being The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 11 considered as a vulnerable area. Some of the information in care plans was difficult to retrieve, there appears to be two documents recording the needs of service users. The manager was aware of the problem and was working with staff to update all care plans to a satisfactory standard. The nurses were able to carry out nursing requirements for those service users who fall into the nursing category, and district nurses attended to carry out any procedure, for the residential service users, e.g. injections or to take blood samples. CSCI service users surveys received said they usually receive the care and support they need, although a number said they often have to wait for staff to give them assistance. One service user said she/he found it sometimes frustrating that she/he is not getting the care they need, often due to there not being enough staff. Risk assessments had been developed to ensure service users could maintain their independence while remaining in a safe environment. The manager ensures risk assessments, for the use of bedrails are agreed with the service users representatives. Service users or their representatives were encouraged to agree and sign their care plan. An audit of medication stocks and records was undertaken these were found to be correct ensuring the health and safety of service users. The local pharmacist is contracted to undertake periodic checks to ensure the stock levels are maintained and procedures are followed. Arrangements are in place for the safe disposal of medication. Nurses had a responsibility for ensuring recording is accurately maintained. Senior carers were responsible for the administration of medication to service users at the residential unit, (the Lodge) they had been appropriately trained. Qualified nurses have responsibility for administering medication at the main unit. Throughout this visit staff were seen interacting with service users in a kindly manner, they spent time talking to service users and were observed knocking on bedroom doors before entering. Privacy and dignity was maintained by staff when undertaking personal care tasks. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is Good. The judgement has been made using available evidence including a visit to this service. Social activities are arranged by the home and service users are able to participate if they wish, to enhance their lifestyle experience. Mealtimes are well managed in the main, and the facilities promote a calm environment with dining areas to accommodate all service users. Service users are encouraged to make choices and control over their own lives. The home has clear visiting policies and procedures to ensure service users can maintain contact with their family and friends. EVIDENCE: Two activity co-ordinators are employed they work between the two units. The inspector observed a number of service users playing bingo in the afternoon of the visit, service users said they enjoyed winning but also enjoyed the company. One of the co-ordinators said arts and crafts and bingo seemed to be the most popular with service users. The co-ordinator also spends time on a one to one basis with service users who don’t join in with group activities. The co-ordinator said that outside entertainers are brought in once a month providing entertainment to both units on the same day; having parties with The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 13 other service users and families also caters for birthdays and other special occasions. CSCI service user surveys said that sometimes activities are arranged but because they are mainly in the afternoon service users don’t join in because they like to have a lay down in their rooms. The visiting hairdresser was spoken to and she said the ladies enjoy having their hair done and it is more of a social event where they meet and chat to other service users. A number of visitors were spoken to during this visit all said that they could visit at any time, and were always made to feel welcome. One relative said she had visited a number of homes prior to choosing the Cedars for her mum, she said she was happy with he home and the care provided by staff, although there were occasions when there did not seem to be enough staff. She said staff worked really hard to make it a nice place to live. The inspectors observed lunch at both units and the food looked well presented, service users were given a choice of two main courses and sweets. Staff worked quickly to serve the meal and assisted service users appropriately. The meals are prepared at the main unit and transferred to the Lodge in a heated trolley. Discussion with staff confirmed arrangements for breakfast and tea. The menus examined suggest that most days’ service users have a choice of breakfast cereals and toast, although cooked breakfasts are available if requested. Soup and sandwiches seem to be the main options at teatime, with the occasional cooked food. CSCI service users surveys received confirmed that service users were generally satisfied with the meals provided but would like more variety at teatime. Service users spoken to said they had enjoyed their lunch. One service user was served a liquidised meal all of the food had been mixed in together making it difficult to distinguished individual flavours. At breakfast and lunchtime most of the service users on the nursing unit sat in wheelchairs at the dining tables rather than being transferred onto dining chairs. CSCI service user surveys said that sometimes there are insufficient staff during mealtimes, as one member of staff is in the kitchen serving the meal while the remaining staff are administering medication, leaving only one member of staff to assist service users with their meal. Staff also had the responsibility to wash the crockery after the meal, which reduces the number of staff to deliver care. A dishwasher, or additional staff would improve the care to service users. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is Good. This judgement has been made by examinations of records, taking to staff, relatives and residents and a visit to the service. Service users and relatives are provided with information to enable them to raise concerns or complaints about the home and the care provided. Adult protection policies, procedures are followed, and action taken if allegations are made, which promotes protection of service users from abuse. EVIDENCE: Complaints systems were in place and records checked showed the home had received four complaints since the manager came into post (September 2006). Records showed that these complaints were completely investigated, and stated what action had been taken with feedback to the complainants. CSCI service users surveys received and residents spoken to said they were aware of the complaint procedure and they felt able to raise any issues with the manager or staff. Adult protection policies, procedures and training for staff were in place, staff had knowledge and understanding, of these issues. The manager would make a referral to adult protection when necessary, this promotes protection of service users from abuse. Service users can participate in community activities if they wish for example by voting in elections either by post or by visiting a polling station. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 15 Information about local advocacy services was available for service users who require assistance in exercising their rights and don’t have any relatives or friends for support. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 16 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, 21, 24 and 26. Quality in this outcome area is Adequate. The judgement has been made using available evidence including a visit to this service, including a tour of the building. The registered provider must continue their refurbishment of the home to ensure the environment is safe and suitable for service users to spend their time. EVIDENCE: A partial tour of communal areas on both units was undertaken and some areas were in need of refurbishment, because some carpets required deep cleaning or replacing as they were worn and dirty Seating in the lounges on both units did not offer a suitable range of options to cater for the varying heights of service users. This was a particular problem for taller service users, who experienced difficulty when sitting in lower chairs. Two ceiling tiles were missing in the dining room (the Lodge), and service users told the inspector that it was sometimes draughty. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 17 The glass on the front door at the lodge also requires replacement, as it is cracked and my cause injury to service users. Lighting was poor on both units, and service users had problems reading newspapers. On the nursing unit a toilet that is used on a regular basis did not have appropriate grab rails installed, therefore this toilet also had a commode in it as some of the service users feel safer using this and not the toilet. Ensuite facilities in bedrooms were in poor repair and the floorings in the toilets were loose and very stained. Laundry facilities were satisfactory, but a lot of black bags full of clothes were in one corner of the room posing a tripping hazard and fire risk. The laundry room ceiling was stained due to a leak from one of the upstairs bathrooms. Sluicing facilities on the nursing unit contained hazardous substances, and there was no lock fitted to the door, which would allow service users to access the substances. This was an avoidable risk. A tour of the bedrooms found them clean and tidy, but wardrobes in some of the bedrooms were insecure, which could cause a major injury if they fell on a service user. Some drawers were in poor repair, bedroom furniture generally needs upgrading to make the rooms more homely. Carpets looked worn and stained and need replacing, walls in some bedrooms were scuffed and in need of painting. A window pane in one bedroom on the nursing unit needs replacing as it is in poor repair. Some service users bedrooms had been made very homely, staff confirmed that service users are able to bring their own personal possessions and memorabilia for their bedrooms, some had been personalised by the service users families with photos and memorabilia. The manager had completed an audit of the environment when he came into the post, and highlighted a number of areas that required improvement, the home didn’t have a maintenance and refurbishment plan for the home, this has been raised in previous inspections. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is Poor. The judgement has been made using available evidence including a visit to this service, and interviews with staff. Staffing levels are not always maintained. Staff had the skills and knowledge to fulfil their role within the home, however some essential training is required. Recruitment policies are robust and followed promoting the safety and protection of service users. EVIDENCE: Examination of staff rotas on both units and discussion with the manager provide evidence that staffing levels are not always maintained. There was only three staff including the care manager on duty at the lodge, on the day of this inspection. The inspectors observed staff who were clearly unable to meet the needs of service users because there was inadequate numbers to service users. CSCI service user surveys and comments gained during the visit also raised concerns that frequently levels were inadequate. An immediate requirement notice was left at the home, requiring that agreed minimum staffing levels be maintained. The inspectors were seriously concerned about the continuing failure to meet this requirement, as this remains outstanding from previous inspections. The organisation has developed a good induction programme for all new employees, although no new staff were available during this inspection to The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 19 confirm induction takes place. Staff levels do not meet the requirement of 50 NVQ qualified staff. A number of staff are working towards the award and a few staff were waiting to commence training in the near future. The manager said that he was developing a training plan to identify gaps in staff knowledge, although this was not available for inspection. Training has been arranged so staff are aware of signs of abuse, and the procedures to follow if any incidents of abuse are reported. Staff were aware of the homes whistle blowing procedures, they said they would report any incidents to the manager. There was a good recruitment procedure that clearly defines the process to follow for the protection of residents. Three new staff have been employed at the home, their recruitment files were examined and contained all the necessary employment checks including references and CRB checks. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 36 and 38. Quality in this outcome area is Adequate. The judgement has been made using available evidence including a visit to this service, and interviews with staff. Staffs at the home were enthusiastic and worked positively with service users to improve their quality of life. But this outcome is affected by a failure of not following health and safety procedures and not providing training and updates for staff. Staff do not regularly receive formal supervision. EVIDENCE: The manager has been in post since September 2006, he has applied to be the registered manager. He had been a registered manager at another home, he is experienced and has completed the registered managers award. He has undertaken some dementia training as part of his own development. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 21 The manager had sent out questionnaires to all relatives for feedback on the service provided. Some had been received back and were available for examination. A number of negative comments were received, the manager had arranged a resident/relative meeting to provide opportunities to discuss any concerns. Other quality audits within the service were completed and evidence was available. Regulation 26 visits were completed on a regular basis, but had not been sent to the Commission for Social Care Inspection, as required by the regulations. The manager said that monthly audits of accidents, pressure sores, medication and care plans were carried out, and action taken if any issues were found. CSCI service users surveys received suggested that staffing levels often meant that service users had to wait to receive their care. Service users money was discussed with the manager, residents can access any money they need, however this is pooled and kept in one account, making it difficult to undertake an audit of individual service users money. Staff do not receive supervision six times a year and there is no evidence to confirm yearly appraisal had taken place for all staff. Safe working practice was both observed and records checked, records showed that the home had up to date current certificates for the passenger lift and hoists within the home. The inspectors issued an immediate requirement as fire training records showed that staff had not received fire training. A fire door was not fully operable and fire safety equipment was not serviced at the prescribed frequency. The fire officer raised some of these issues on their visit in October 2006. The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X 2 X X 2 X 2 STAFFING Standard No Score 27 1 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(2)(b) Requirement Timescale for action 31/03/07 2 3 OP19 OP19 23(2)(b) 23(2)(b) ( c) Care plans must have full information to give staff direction with regard to activities, social, psychological and mental health needs. (Timescale 01/07/05 & 01/01/06 Not met) Ceiling tiles in the lounge (the 28/02/07 Lodge) must be replaced. Carpets and floor coverings in 01/04/07 communal areas and service users bedrooms must be thoroughly cleaned, and kept clean. Seating in the lounge on both 01/05/07 units must be replaced with more suitable range of options to cater for the varying heights of service users. Communal areas and corridors must be suitably lit to ensure service users can move around safely. Lounges must suitably lit to ensure service users can take part in daily activities such as reading newspapers. 01/04/07 4 OP19 23(2)(c) 5 OP19 23 (2)(c) (p) The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 24 6 OP19 23 (2)(b) There must be a maintenance and renewal programme to ensure that carpets and decor are regularly maintained and replaced with specific timescales. This as been highlighted in previous inspections. A copy of this programme must be sent to the Commission for Social Care Inspection local office. (Timescale 01/08/06 not met.) The sluice must have a lock fitted, it must kept locked at all times except when in use. All the bathrooms and ensuites must be upgraded with new floor coverings where required. (Timescale 01/04/06 Not met) 1) Wardrobes must be secured to the walls in bedrooms. 2) Bedrooms must be kept in good repair with regards to carpets, furniture and décor. Black bags that are full of unwanted clothes must be removed from the laundry room. Sufficient numbers of staff with appropriate skills must be duty to meet service users needs. (Timescale 01/07/05 & 01/12/05 Not met) 31/03/07 7 OP21 23 (2)(l) 28/02/07 8 OP21 23 (2)(b) 31/03/07 9 OP24 23 (2)(b)(d) 31/03/07 10 OP26 23(2)(b) 13(4)(c) 18 (1)(a) 28/02/07 11 OP27 03/02/07 12 OP28 18(1) (c)(i) 18(2) 13 OP36 NVQ training must continue to 01/04/07 ensure a minimum ratio of 50 of care staff trained to NVQ Level 2 or equivalent is achieved. Staff must receive supervision 31/03/07 six times a year. DS0000015852.V312296.R01.S.doc Version 5.2 Page 25 The Cedars Nursing Home 14 15 16 OP38 OP38 OP38 23(4)(b) 23(4)(d) 23(4)(c) (iv) All fire doors must be fully operable. All staff must receive fire training. 08/02/07 08/02/07 All fire safety equipment must be 28/02/07 serviced in compliance within the prescribed frequency. 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 OP15 Good Practice Recommendations The cook should ensure that when preparing liquidised food for service users it should be individually liquidised to enable the service user to distinguish the foods they are eating. A dishwasher, or additional kitchen staff should be provided to ensure staff can deliver the care to service users. The menus should be reviewed, especially the teatime options. The preferences of service users should be sought, and menus should reflect their wishes. Service users should be transferred into dining chairs at mealtimes, this aids pressure care and maintains the dignity of service users. 2 OP15 3 OP15 4 OP14 The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Cedars Nursing Home DS0000015852.V312296.R01.S.doc Version 5.2 Page 27 - 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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