Inspection on 11/04/08 for The Cedars Nursing Home

This inspection was carried out on 11th April 2008.

CSCI found this care home to be providing an Adequate service.

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 14/11/08

The Cedars Nursing Home 25/09/07

The Cedars Nursing Home 05/07/06

The Cedars Nursing Home 15/11/05

The Cedars Nursing Home 02/06/05

The Cedars Nursing Home 27/01/05

The Cedars Nursing Home 15/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Cedars Nursing Home (The) Northlands Landford Salisbury Wiltshire SP5 2EJ Lead Inspector Susie Stratton Unannounced Inspection 09:35 11th April 2008 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 Nursing Home (The) DS0000015897.V358653.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 Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedars Nursing Home (The) Address Northlands Landford Salisbury Wiltshire SP5 2EJ 01794 390284 01794 390068 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) Alphacare Holdings Limited Mrs Marilyn Bulmer Care Home 31 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (31), of places Physical disability (10) Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated in the home at any one time is 31 No more than 10 service users over the age of 50 years with a physical disability may be admitted at any one time and admission criteria for those between the ages of 50 and 65 must be consistent with the home’s statement of purpose The minimum staffing levels set out in the Notice of Decision dated 6 November 2003 must be met at all times 25th September 2007 3. Date of last inspection Brief Description of the Service: The Cedars Nursing Home is registered to provide nursing care for 31 people aged 50 years and older. The home is an older building, situated in rural location on the A36 mid-way between Salisbury and Southampton. Accommodation is provided over two floors with a passenger lift in-between. Many of the rooms are single and provide comfortable accommodation. The home has large surrounding grounds and pleasant views of the countryside. There is car parking on site and a bus stop at the end of the drive. At the time of the site visit, there were 27 persons resident in the home. The Cedars is owned by Alphacare Holdings Ltd and the Registered Manager is Mrs Marilyn Bulmer, who has been in post since autumn 2000. She is supported by registered nurses, care assistants and ancillary staff. The fee range is £547.95 to £895 per week. Additional costs include chiropody, hairdressing, newspapers and sundries, such as toiletries. Systems for making the service users’ guide available to people were not clear. Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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. As part of the inspection, 40 questionnaires were sent out to residents and their relatives and 18 were returned. Comments made by people in questionnaires and to us during the inspection process have been included when drawing up the report. After the last inspection we held a meeting with two senior managers from Alphacare Holdings limited, the owners of the home. Following this meeting, they submitted a detailed improvement plan. The home were also asked to submit an additional annual quality audit, to inform the inspection process. As part of this inspection, the home’s file was reviewed and information provided since the previous inspection was considered. The site visit took place over one day, on Friday 11th April 2008, between 9:35am and 6:00pm. It was conducted by two of our inspectors. The manager, Mrs Bulmer came on duty during the afternoon of the site visit. A brief feedback was given to the manager after the inspection and a more detailed meeting to feedback to senior managers within Alphacare Holdings Ltd has been arranged. During the site visit, we met with different residents on both floors of the home, we met with some people in the sitting and dining rooms and others in their own rooms. Where residents found communication difficult, we observed the care given to them. We reviewed care provision and documentation in detail for a range of residents who had different dependency, nursing and care needs, some of whom had been admitted recently. As well as meeting with residents, we met with three registered nurses, six carers, the cook, a kitchen assistant, three domestics, the administrator and an activities coordinator. We toured all the building and observed a lunch-time meal. We observed systems for administration of medicines and a medicines administration round. A range of records were reviewed, including staff training records, staff employment records, maintenance records and financial records. What the service does well: The Cedars is a large country house, which has extensive, well maintained grounds. Many of the rooms are large and people are able to bring in personal items, this gives many of the rooms an individual flavour, reflecting the resident’s likes and preferences. Much effort has been put into ensuring that there are highly individual care plans, which reflect the different ranges of Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 6 needs of people resident in the home. Recreational needs are regarded as a key area for residents and a range of different activities are provided by enthusiastic staff. One person reported “I like the activities that draw people together” and a relative commented “When I see my relative in the residents lounge they all seem to be treated as one”. Residents reported that staff were supportive of them and that they responded quickly when they used their call bells. One person reported “I’ve got a bell and they come straight away if I want them” and another “If I want a member of staff, I shout for them”. Residents expressed their appreciation of the home. One person reported “Everything is perfect”, another that the home was “Always warm and friendly”, another “It’s very nice here as far as I’m concerned” and another “We are comfortable and well fed with people around us to talk to”. People also commented on the staff, one person reported “I am definitely well cared and looked after” another “I am happy at the Cedars and I get on with staff well”, another “It’s the right place. I’m very happy. Every-one is so helpful” and another “They are very good staff and very helpful”. What has improved since the last inspection? At the previous inspection, 20 requirements and 14 good practice recommendations were identified, of these 12 requirements had been addressed in full and all the other requirements showed progress. Of the fourteen good practice recommendations, eight had been addressed, one showed progress and one will be addressed when the new extension has been completed. Residents now have assessments of their needs drawn up. Assessments and care plans are reviewed monthly or when a resident’s condition changes. Care plans relating to wound care have been improved. Where a resident needs support in moving themselves or taking in an adequate diet or fluids, a monitoring record is now in place, so that staff can ensure that the needs of these frail people are being met. Frail residents’ fluid intake is totalled every 24 hours. Where a resident’s GP or an external healthcare professional makes directives, there was evidence that these directives have been carried out, or if they have not been carried out, the reason why this is. A new blood testing device has been obtained. All medicines and dosages (including oxygen) are listed on the medication administration record. Medicines which have a shortened expiry date after opening are dated when first opened. Most divan beds have been replaced by variable height beds. A copy of the Health and Safety Executive’s directives on the use of safety rails has been obtained and considered when developing documentation relating to safety rail assessments. A review of staffing levels is in progress. No staff have been employed until all checks relating to their suitability have taken place. Photographs of staff are Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 7 clear and provide a proof of identity. Training records have been reviewed and up-dated to provide evidence of training participated in by staff. Staff have been trained in infection control. The company policy on reviews of quality of service has been implemented. There are now clear records of the circumstances of any accident to a resident. What they could do better: At this inspection, 18 requirements and 12 good practice recommendations were made. Of these requirements seven were in progress from the last inspection. One good practice recommendation was unmet from the previous inspection and one had not been addressed in full. Prospective residents and their supporters will not be informed of all services offered by the home, as the summary of the most recent inspection report and terms and conditions of residence are not available in the service users’ guide. The service users’ guide needs to be readily available to all people who would wish to review it. The information in the service users’ guide needs to be revised, to fully reflect all matters relating to the services provided by the home. Improvements continued to be needed in certain aspects of the provision of nursing and care. Full care plans continue to be needed in some aspects of nursing and care, to direct staff on specific how needs for individual residents are to be met. Staff should be trained to use care plans as working documents. When monitoring charts are used to document nursing and care given to residents, they must be accurate. Improvements are needed in administration of medicines. All registered nurses must always perform medicines administration in a safe manner and must not document that a person has taken their medication until this has taken place. Prescribed items which have been discontinued or which were prescribed for a resident who has died must be safely stored. Items must be disposed of as soon as is indicated. Where a resident does not take a prescribed item, there must be full records relating to this. Care plans relating to medication must be developed, this includes medicines prescribed as required, where a resident wishes to self-medicate or where a medicine can have an effect on a resident’s well-being. As at the last inspection, where a resident needs support to eat, this must always take place. Where a person has a change in dietary requirements, the kitchen staff need to be informed, as well as nursing and care staff. Practice should be reviewed so that residents are not taken to the dining room for an extended period before their meal, unless they wish to do so. The practice of leaving residents in wheelchairs and not transferring them to appropriate chairs when in communal rooms should be reviewed. The practice of mixing all liquidised foods together should be reviewed. Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 8 Equipment needed by residents to prevent risk of pressure damage continues not to be provided in all cases, in accordance with the individual’s assessed degree of risk. All sanitary items and items used in nursing and care must always be maintained at full standards of cleanliness. Equipment provided must be intact, so that it can be properly cleaned and not present a risk of cross infection. This matter was identified at the previous inspection. Equipment used in resident care should be stored away from the floor and any stained items be disposed of. Audits of infection rates should be included in the homes’ own quality audit. It was required at the last inspection that a full written review of staffing levels must take place. This was in progress but had not yet been addressed in full. Residents must not be left unsupervised for extended periods when in the sitting or dining rooms. The home continues not to use their interview assessment tool to assess prospective staff. Practice at this inspection indicates that not all staff have been trained areas relating to provision of nursing and care to elderly people. Full records of training to meet resident’s specific needs need to be in place, to ensure that the staff on duty are trained in how to meet such peoples’ needs. All registered nurses should have their competencies for administration of medicines regularly assessed and written records maintained. There continues to be a need for evidence that all staff have been supervised in their role and that an on-going programme has been put in place to ensure that staff are supervised. Where safety rails are being used on resident’s beds, all care plans relating to need still need to be regularly evaluated. Care plans relating to the use of protection to safety rails continue to need to be complied with. The home must ensure that it regularly reviews hazard notices and guidelines and ensure that relevant risk assessments are drawn up and complied with. Issues relating to a different hazard notice was noted at the previous inspection. 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 Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 9 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 Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 10 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): 1 & 3. The Cedars does not admit people for intermediate care, so 6 is N/A Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents are able to find out about the home by visiting it prior to admission and having a full assessment of their needs, however written information provided to people needs up dating, to ensure that it fully reflects the services provided. EVIDENCE: The Cedars has a statement of purpose and service users’ guide to inform prospective residents and their supporters of the services provided, however a copy of the guide was not available in the front entrance hall or in residents’ rooms, as happens in other care homes. The home’s office moved just before this inspection and staff did not know where the current service users’ guide was kept, until the manager returned. The manager reported that all prospective residents are given a copy of the guide but this was not evidenced by other documentation. Of the sixteen people who responded to this section Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 11 of the questionnaire, fourteen felt they had enough information about the home, but two did not. The guide inspected has been up-dated in some areas since the last inspection, however it still needs more work. The guide did not include a copy of the summary of the most recent inspection and this is needed to inform prospective residents of how the home meets National Minimum Standards. The guide also did not include a copy of the standard contact/terms and conditions of residence. It was reported that this was because the contract was currently being revised to ensure that it conformed to current regulations and guidance. We were shown a copy of the draft contract, which it was reported would be issued to all residents, once it had been agreed. The service users’ guide also needs up-dating in several sections. The section relating to inspection does not conform to our current practice. The section on reviews of care plans does not agree with National Minimum Standards. There is no mention of self medication. Payments for extra services do not relate to what occurs in the home at present. Whilst the total number of staff are documented, the numbers and skill mix per shift are not included. The Guide refers to the previous registering authority, not us. The annual quality audit submitted to us prior to the inspection, did not report if the home’s information systems had been reviewed since the last inspection or in the light of any changing resident need. Residents reported that they had either visited the home or a relative had done this on their behalf, prior to being admitted. One person said that their relative reported that they “thought this was the best home, out of the ones he looked at”. Another person reported “We asked for a brochure, visited by appointment and were shown round by staff qualified to answer our questions”. The manager reported that she meets with all prospective residents prior to admission and assesses their needs. One person reported, “Matron came to see me”. The home’s annual quality audit indicated that much work had been put into developing assessment of resident need prior to admission and assessment documentation has been revised. The new documentation is more detailed, to ensure that all areas relating to prospective residents’ needs are considered prior to admission. The manager writes individual letters to residents and/or their supporters prior to admission to confirm that the home can meet their needs. A relative reported “We are particularly impressed by the Matron who has helped the “settling in” process with practical help and sympathetic understanding.” Cedars Nursing Home (The) DS0000015897.V358653.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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Many aspects of residents’ personal and healthcare needs are met by the improved systems developed since the last inspection, however practice relating to administration of medicines and provision of care to very frail people still need to be improved, to reduce risk to residents. EVIDENCE: Since the last inspection, staff have put extensive work into improving assessments of need and care planning. Care planning systems have been much developed. All residents now have a very full and detailed care plan, which reflects much of their needs and which they or their supporters have been party to. Care plans are generally evaluated monthly or when a person’s condition changes. In many areas, care plans reflected what residents reported or what we observed. The care plans inspected by us were highly individual and very detailed. The manager and her staff are to be congratulated for all the work they have put into this area. One relative reported “They are always Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 13 very caring to my relative”. A resident reported “I know that the staff are always there when I need them” and another “When I run into trouble or need help they can get me out of it”. Work is still needed in certain areas, particularly relating to very frail people who are not in a position to comment on their care plans. Two of the staff on duty on the first floor reported that they generally worked on the ground floor and so did not know the care needs of the residents on the first floor in detail. They reported that they had received a report on residents’ needs when they started their shift. However they were not observed to go in and out of the office where the care records were kept, to check up on matters of detail in care plans as is generally observed in other care homes where staff are working in similar situations. This indicates that some work is still needed to ensure that care plans are working documents, being used as a tool by staff to inform them of residents’ individual needs. The registered nurse in charge of the first floor did have a very full and detailed knowledge of all the residents on her floor. While all residents had a risk assessment relating to pressure damage, one of the persons assessed as being at high risk of developing pressure damage did not have a care plan to direct how risk was to be reduced for them. None of the other care plans relating to reducing risks of pressure damage stated how often the person needed to have their position changed and some of the equipment documented to be used to relieve pressure was not what was observed to be in use. For example one person’s records stated that they had an air mattress on their bed but when they were visited they did not have one, although an air cushion was provided on their chair. One resident who was assessed as being at high risk of pressure damage was observed to spend nearly all their day out of their room in the sitting room, this was agreed with by staff to be how the person generally did spend their day, but the person’s care plan relating to reducing risk did not consider this. Additionally the equipment to prevent risk of pressure damage provided to this person when they were not in their room related to a person with medium, not a high risk of pressure damage. Several residents were assessed as needing thickening agent to ensure that they could swallow safely. This was documented in their records, however as different people need fluids thickening to a different consistency, according to their individual need and risk of choking, the consistency of the liquid needed by the person (syrup, custard or jelly), should also be documented, to ensure that a person is not at risk of choking. Observations of care indicated that staff were not always providing the care that people needed. All frail people now have charts in place to ensure that the fluids and meals that they are able to take in are documented. The amount of fluid taken in by a person is now totalled every 24 hours. Many of these charts were an accurate reflection of the care given, documenting the type of Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 14 fluid or how much was eaten, however staff did not at all times complete these charts in a consistent manner. For example, one person was observed to be given a cup of coffee and two biscuits during the morning, which it was observed that they ate and drank, but this was not documented. Another person was documented as being given a full beaker of juice, however the juice was observed to be left untasted throughout the morning of the inspection. We saw a fluid balance chart in one bedroom at lunchtime that had not been filled out since 9.20am. This meant that we could not establish whether the residents had been given a drink since then. We saw a jug of water on a tray in the sitting room but there were no glasses. One person who had a very clear care plan relating to their needs for assistance to eat, particularly relating to concentration difficulties, was observed to be given a meal at 12:40, which they could not concentrate on to eat. This was removed at 13:10, when it was cold and it was documented that they had “refused” to eat. This was not an accurate reflection of what occurred. Our observations indicated that these matters did not necessarily relate to staff not attending to individual residents’ needs, more to their availability (see section 6 below). Most residents who needed thickening agent had had this put in their drinks, however on one occasion, this was observed not to take place. In the home’s improvement plan it was stated that all postural changes will be documented and that this will be monitored by the trained nurse and also by the home’s management team. The home now does record changes of position for residents who are not able to move themselves. This is particularly important for people who are at risk of pressure damage. However these charts did not indicate changes of position in every case, many of the night records simply stated “checked”, not that the person had been moved. During the inspection, it was observed that two people who were assessed as being at high risk of pressure damage did not have their positions changed to relieve pressure on their sacral areas. For one person this was likely to have been for a period of nine hours and another at least seven hours. These observations were unlikely to be “one off” occurrences, as a range of previous turn charts reviewed did not indicate that changes of position were being routinely recorded. Current guidelines state that even where pressure relieving equipment is provided, people at high risk of pressure damage still need to have their positions moved on a regular basis, in accordance with their individual needs. Our observations indicated that the reasons for people not being moved related more to staff availability (see section 6 below) rather than staff not being prepared to provide care, in accordance with guidelines. Where a person was unwell, prompt assistance from relevant healthcare professionals was sought. One person had been noted not to be well the early morning before the inspection, their GP was called in and they visited during the late morning. One person reported “The doctor is always called in when I need her” and one relative reported “As this had always been a priority we are very grateful that it is given”. There was evidence that other healthcare professionals supported the home. One resident had recently been visited by a Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 15 stoma nurse and detailed records made in their records about how care in relation to the stoma was to be provided. The stoma nurse had documented that certain prescribed skin application was not to be used, however it was observed to be still available in the person’s bedside locker. The stoma nurse had also revised an earlier plan about the person’s dietary needs. The chef had not been made aware of these revisions to the person’s dietary needs and the chef’s records related to previous advice. The Macmillan Nurse had also visited the home and had suggested revisions to a resident’s care plan. The home has safe systems for storage of medication and most records are maintained, to provide a full audit trail of medicines brought into the home, given to residents and disposed of from the home. However attention is needed in some areas. A tablet was found on one resident’s bed-side table, however the person’s medicines chart had been signed as having been given, which indicated that the member of staff performing the medicines administration had not performed the round in accordance with good practice guidelines. Another registered nurse was observed to dispense tablets relating to another resident into pots a period before they went to the resident. This is seen as a risk, tablets should only be dispensed into pots when a registered nurse is with the resident. Most records relating to administration were completed in full and if they were not, a record was made of why the person did not take their medication, however this was not consistently happening in all cases. One person’s records indicated that they had not taken a moodaltering drug on one occasion recently but there was no record of why this was. The Controlled Drugs were reviewed. Controlled Drugs were safely stored. The Controlled Drugs register was not clear in all cases. Records relating to one Controlled Drug and one schedule two drug had been both documented on the same page in the Register. This made audit confusing. There was a container of tablets in the medicines cupboard, this related to “found/dropped” tablets. The record relating to this had not been completed since 2005. While it is appreciated that it may not always be possible to identify what the tablet was, the record needs to state who the resident may have been who has not taken their tablet, so that an assessment can be made of whether this is a matter which needs to be noted and the person’s GP advised. All medicines for disposal were stacked at the bottom of the medicines trolley on top of other articles, such as a bag of cotton wool. Both discontinued medicines and medicines relating to people who had died were stored there. Medicines for disposal need to be disposed of promptly. Medicines which have to be kept for a period after a person has died need to be clearly labelled as such and put into a separate container, until they can be disposed of. Three cylinders of oxygen prescribed for a person who had died a period ago remained in a storage cupboard. The supplier of the oxygen needs to be contacted to remove the cylinders. Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 16 It was reported that no residents were self-medicating. An inhaler was noted in one resident’s room. Their medicines chart indicated that they were prescribed this inhaler when required and that they did need to use the inhaler at times. There was no care plan relating to the use of this inhaler, whether the person was partially self-medicating and what symptoms they had when they needed to use/be supported in using the inhaler. The registered nurse performing the medicines round during the inspection reported that they usually worked on the ground floor and were unaware of the detail of individual’s needs. A care plan for the use of the inhaler is needed, including a risk assessment for selfmedication, if indicated. One resident was reported to be reluctant to take all of a liquid preparation, although it was reported that their medical condition indicated that they needed it. The registered nurse reported that the practice was to increase the dose, so that when the person took half the amount needed they would actually take the amount prescribed. This practice was not supported by a care plan or any evidence that it had been agreed with the resident’s GP. Some residents were prescribed medication which could affect their daily lives, such as mood altering drugs and painkillers. While some residents had such medication documented in their care plans, not all did. Some care plans relating to bowel care stated “give aperients as prescribed” but did not assess the effectiveness of aperients when evaluated. A person was prescribed a major mood-altering drug but there was no mention of this in their care plans, so no assessment of the effectiveness of this drug had taken place. Another resident had a care plan relating to physical and verbal aggression. The manager was able to report on how effective a mood-altering drug had been in stabilising this condition, however this had not been documented in their care plan, which should have stated the drug used, together with an assessment of how it had improved the person’s condition. Issues relating to medicines management have been referred to our pharmacist inspector and a random inspection will take place before the next key inspection, to review medicines management in the home. Staff at all levels were noted to consistently knock on residents’ doors and await a reply prior to entering their rooms. All personal care was provided behind closed doors. Residents, including those who were confused were attractively dressed, with attention to matters such as clean glasses, fingernails and brushed hair. One resident was observed to need more support in trimming facial hair. Staff were observed to care for one resident who was not aware of their own needs for ensuring their dignity. They cared for this person in a highly appropriate manner, ensuring that the person remained fully covered whilst they were being assisted to transfer to another chair. Care plans identified how residents wished to be addressed. All residents own personal laundry was returned to them. Cedars Nursing Home (The) DS0000015897.V358653.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are supported to chose how they spend their daily lives, this includes recreational activities and meals. EVIDENCE: Those residents who could decide, followed their own routines. Other residents relied on staff for direction. We met with one resident who said they liked to get up later. We saw that this was noted in their care plan. One resident reported “I don’t think the staff would dare to put me to bed early”. Another resident reported “I don’t like having drops put in my eyes at 6:30 when I’m asleep”. The manager reported that such matters had been identified as an issue and that medicines would be administered later in the morning when the new wing was opened. Each resident had a social care plan identifying what they liked to do and what hobbies they were involved in. There was good evidence in the social diaries that residents were offered a range of activities. We talked with residents about their daily routines. Of the fifteen people who responded to this section Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 18 of the questionnaire, twelve reported there were always, two usually and one never activities provided which they could take part in. We talked with residents about the activities provided. They said they looked forward to the art classes. They had decorated eggs for Easter and we saw these on display in the dining room. They said a member of the activities staff takes them to Salisbury shopping, for a ride in the countryside or to a café. Residents told us they could sit in the gardens in the summer. One person reported “Especially enjoy painting sessions and group singing”, another “I enjoy to paint and to sing I like to play bingo” and another “I go to anything that’s on – the activities are really good here”. Mrs Bulmer told us that the deputy matron often bakes cakes with the residents. Other activities included music and movement, bingo and quizzes. We spoke with one of the two people who provides activities in the home. They were providing an art session in the dining room. They told us how they researched to find different activities so that each resident achieved a finished piece of work regardless of artistic ability or dexterity. She told us that the process was what residents enjoyed. They said they had a small budget for buying resources and prizes for different games. They told us there was no set programme of activities, they asked residents what they wanted to do. Mrs Bulmer told us the activity programme was on the notice board by the sitting room but we could not find it. She later showed us a copy. Activities take place each morning and afternoon. Generally the activities are group work. However we did see evidence in one care plan of some one to one time for those residents who may not want to join groups. One person described the activities coordinators as “both very nice people” and another described how one of the activities persons had “go”. We saw that nine residents in the downstairs dining room were still waiting for their lunch to be served at 1.10pm. Some of these residents had been brought to the dining room at 12.30pm. We noted that 5 residents were left in wheelchairs during lunch. Some residents who were looking forward to the afternoon activity person coming to do an art session, were concerned that lunch would not be cleared away in time. Residents who ate in their own rooms were provided with lunch from 12:30pm. Where residents needed physical assistance to eat, staff sat with them supporting them and encouraging them to eat. The home operates a four week menu. The chef said that this was supplied by the company but he made changes according to what residents liked. Of the sixteen people who responded to this section of the questionnaire seven reported they always, seven usually and two sometimes liked the meals. Residents we spoke with made very positive comments about the meals, including during the lunch. Comments included “Always quite good”, another, “The meals are very good. No I wouldn’t like to change anything about the meals” and another “Considering that it is a home, I think they are rather good. I don’t think the portion size is out of place and is good for a woman.” Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 19 One person who always ate in their room commented that the food was “nice and hot”. We saw good stocks of fresh fruit and vegetables in the stores. Residents were asked by staff what they wanted for the following day’s meals. We asked residents if it was possible to remember what they had chosen that far ahead and most of those we spoke to could say what they were having. However one person did report “They bring you the menu and you choose what you want but you then eat what you’re given”. The meal was either fish and chips or ham, egg and chips. Some residents had mashed potato. Some residents had their ham minced. One resident had a jacket potato with cheese. A resident reported that they “can have something else if I don’t like it”. One residents had a bowl where all the ingredients had been pureed together. This meant that the meal looked unappetising; a grey green colour. The resident however told us that it tasted nice. The pudding was either rice pudding or ice cream. There were only two members of staff in the downstairs dining room to support residents with lunch. One member of staff came down to help serve puddings. One resident who had attention difficulties was not supported at lunchtime (see section 2 above). One of the two members of staff was called away from supporting one resident with eating, to meet with the GP (see also section 6 below). This meant that both resident’s food was going cold. We saw that staff sat by residents who they were supporting to eat their lunch. The meal was unhurried and spoonfuls of food given at the residents pace of eating. Staff engaged with the residents whilst they were supporting these residents. They were also mindful of the needs of the other residents during the meal. Residents’ likes and dislikes with regard to food and meals were detailed in their care plans, however as noted in section 2 above, one person’s dietary needs were not up-dated when the stoma nurse gave further advice about the types of meals they were to be given. Residents had three choices of squash at lunchtime. Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 20 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The Cedars has policies and procedures in place to ensure that adults are safeguarded and complaints responded to. EVIDENCE: A complaints procedure is available in the service users’ guide and is displayed in the entrance hall. Of the eighteen people who responded to this section of the questionnaire, all reported that they knew how to make a complaint. One person reported that they would talk to “Members of staff or Matron”, another “It depends on the problem but I would usually ask to speak to Matron” and another “I would tell the nurse”. One resident told us they did not know how to make a complaint. Another told us that they did not know whether there was a complaints procedure. The latter comment may relate to the lack of availability of the service users’ guide to people in their rooms (see section 1 above). Mrs Bulmer kept a log of any complaints. This showed good detail of any investigations, actions taken and responses to complainants. No complaints have been made to us about the service since the last inspection. The home has a safeguarding adults policy, this conforms to local guidelines as well as national policy. No safeguarding referrals have been made since the Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 21 last inspection. Records and discussion with staff showed that all staff are regularly trained in safeguarding adults. The recently employed administrator reported that safeguarding adults had been part of her induction programme. Three members of staff were observed to care for a resident who had aggressive behaviours. They dealt with this person in a highly professional manner, respecting the person’s dignity, despite a degree of aggression from the person, including hitting out and pinching. At no time did any member of staff raise their voice, although at least one person may have experienced discomfort from the resident’s physical aggression. The whole focus of care appeared to be to minimise the affect on the resident, to make them calm and comfortable again. Staff are to be congratulated for their kindly and yet highly professional manner. Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 22 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, 20, 22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents in the Cedars are provided with spacious accommodation and equipment to meet their need is provided. Some areas need attention but these will be addressed when the new extension opens. A few areas relating to cleanliness and prevention of spread of infection continue to need to be addressed. EVIDENCE: At the time of the inspection, a 40-bed extension was nearly completed to the rear of the building. Mrs Bulmer reported that when the extension was completed and registered, that residents currently in the Cedars would be moved into the new extension and the original building be up-graded. This is needed. For example, the carpets in the corridors were wearing thin and were discoloured. The Cedars has one spacious sitting room and a large dining Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 23 room. It also has the benefit of extensive, attractively laid out gardens. One person reported “I like my room and the views from the window” and another “I’ve got a beautiful view” Much work has been put into provision of equipment to meet the needs of people with a disability or who are frail since the last inspection. New commode chairs have been provided throughout the home. Profiling beds have been provided and Mrs Bulmer reported that more were on order. Some of the residents, particularly those on the ground floor had older style hospital metal beds, which had the paint coming off through age. Mrs Bulmer told us that new beds would be supplied when residents moved to the new accommodation. Old style mattresses have been replaced since the last inspection. An increased amount of equipment to prevent pressure damage was now being provided, although some more equipment is still indicated (see section 2 above). One bath hoist was in use where additional equipment is needed to prevent a hazard to certain residents. There was no risk assessment in relation to this and the temporary equipment did not conform to guidelines. Mrs Bulmer reported that this bath hoist would not be moved to the new extension. A requirement relating to a different matter covered by the Medicines and Healthcare Regulatory Authority (MHRA), relating to blood testing equipment was identified at the previous inspection. Directives from the MHRA need to be regularly considered by management in the home, to ensure that the safety of residents and staff are being maintained. Residents reported that they could bring items of their own in if they wished, this included furniture. Many rooms were very individualised, reflecting the person’s likes and preferences. One person showed us their room, reporting “All these ornaments & stuff are mine”. We saw that one resident’s divan base and mattress were very stained. Mrs Bulmer told us that this was the resident’s own bed that they had brought with them. She went on to say that the resident would have a new bed when they moved across to the new building. Some of the bedrooms were cold. One resident had a jacket on and was sitting in their chair with a blanket over their legs. We noted that the radiator was not on. They said they were not cold in bed when we asked them. Two of the corridor radiators were very hot to touch. Mrs Bulmer reported that issues relating to the heating system would be rectified when the Cedars was upgraded. There were no unpleasant odours detected at any time during the inspection. Of the fifteen people who responded to this section of the questionnaire, eleven people reported that the home was always, three usually and one sometimes fresh and clean. One relative commented “We are particularly sensitive about this but have no reason to be concerned”. Standards for cleanliness have improved markedly since the last inspection, we found the toilets, bathrooms and sanitary items to be cleaned to a good standard. When Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 24 we visited one resident with confusional needs, we found that they had removed their used continence pad and had placed on the floor of their room. When they were visited a short time afterwards, this pad had been disposed of. However some areas still need attention. Both of the brushes for cleaning commode buckets were placed in liquids with brown matter floating in them and neither brushes were clean. Brushes for cleaning commode buckets need to be cleaned after use and stored dry to prevent risk of cross infection. We also saw dried brown matter on the sides of a downstairs sluice bucket and dried on brown staining under the lip of a slipper bed pan on the first floor. The plastic coating of the lid of one clinical waste bin was coming off, with the under surface showing and so could not be wiped down, to ensure that it was clean. In the shower room, we saw a topical cream that was prescribed for a resident who no longer in the home. Communal use of topical applications is a major risk to cross infection. At the last inspection, it was required that all staff be trained in their individual responsibilities for the prevention of spread of infection. This indicates that while records show that this has taken place, that some staff continue not to be aware of their responsibilities in this area. One resident needed to use ostomy equipment, this was observed in their en-suite. The equipment was not placed on shelving but was spilling out of boxes onto the floor. Additionally two straps relating to their equipment which were stained yellow/brown, were observed in their bedside cabinet. Another resident had an unclean collar and cuff on the floor of their room under their wash hand basin. This equipment does not need to be sterile but such equipment should be appropriately stored and any unclean equipment disposed of promptly. We met with one domestic who reported that equipment provision had improved since the last inspection. They said that the new carpet shampooer functioned far more effectively and was lighter and easier to use. The reported that now the home had more variable height beds that they could clean much more easily underneath them. They also reported that they had a good supply of cleaning materials and protective clothing. It was reported in the annual quality audit that there was a new contract for cleaning materials to further develop practice in this area. We visited the laundry. The area was clean and well organised with proper precautions in place for the handling of soiled or contaminated laundry. New laundry skips had been purchased to ensure proper separation of laundry. We were informed that the sheets were cleaned by an external laundry company. Registered nurses reported that no residents currently needed dressings to be performed using aseptic procedure. Cedars Nursing Home (The) DS0000015897.V358653.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Issues relating to staffing have not improved since the last inspection and it appears that, due to this, not all residents were having their needs addressed. Training is being developed, but more work is needed to ensure that staff have the skills to meet resident need. Staff are generally safely recruited. EVIDENCE: At the previous inspection, issues relating to meeting residents’ needs, which could have related to the number of staff on duty were identified. The home were required to review its staffing levels, to ensure that it could meet the needs of people resident in the home. In their improvement plan, the providers reported that staffing was “regularly under review” and “is determined by the dependency levels of the service users being cared for and the layout of the building is also taken into consideration.” It was reported that the home manager had the autonomy to “flex staffing” to reflect the dependency levels of the residents. Mrs Bulmer reported that she did not have difficulty in the recruitment staff and that she had not needed to use agency staff for an extended period of time. The home does not operate a bank as such but it was reported that staff were prepared to work flexibly to cater for sudden absences, such as sickness. The manager reported in the annual quality audit that the home experiences very low sickness rates. Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 26 We looked at the staffing rota. One of the staff told us that the previous day there had only been four staff in the building; two on the ground floor and two on the first floor. They told us that the rota was inconsistent; sometimes there were seven or eight staff and only five at other times. We saw that residents spent a large portion of time without staff in both the sitting room and the dining room. This could be unsafe as some residents had unstable medical conditions and/or additional mental health care needs. We tried to use the call bell in the dining room when one of the residents told us they wanted some staff support. The call bell was missing from its place on the wall. Mrs Bulmer attended and found the bell on the side. She attended to the resident. We asked staff about the staffing arrangements for the laundry. On the day of the inspection, three full bags of used laundry were observed on the first floor, staff reported that as they needed more towels, they would need to perform the laundry, so as to have more towels, even if they were busy. This means that staff will be will be taken away from caring for residents. Mrs Bulmer reported to us that more towels were being purchased, to avoid this being an issue in the future. We observed staff working practice and it was observed that staff were very busy throughout the inspection. The home cares for many residents who are at high risk of pressure damage but records and observations did not show that they had had their positions changed at the frequency that would be anticipated, considering their high degree of risk. One relative commented in the questionnaire “The only comment that I would make is that I feel that my relative is sometimes kept up in her chair when she desperately needs to go back to bed. She is unable to move and is completely dependant on the staff and finds that sitting in her chair is very uncomfortable after a while.” As noted in section two above, one resident did not receive the care that they needed as set out in their care plan at the mealtime. These factors appeared to relate to lack of staff to meet such care needs, rather than staff not being able or prepared to meet needs. Staff in the main dining room were also noted to be very busy, engaged in different tasks at lunchtime, (see section 3 above), rather than being able to concentrate on meeting residents’ needs. The residents we spoke with made very positive comments about the staff. It was clear that good relationships had been established. However most of those residents told us that staff did not have time. One resident reported “I don’t see a lot of the staff”, another “Staff don’t have time to sit and chat” and another that the home needed to “Have more staff on so they have more time to do extras”. Some people commented that they felt that staffing was worse at the weekend. One person commented “We do not understand why weekend staff are so much less than weekdays. We still have the same needs” another person commented about staff availability “Weekends – not so good”. We discussed the issue of staffing levels with Mrs Bulmer, who reported that staffing levels are under review and plans are in the process of development, Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 27 including introducing different shifts for busy periods of day and a review of job roles and responsibilities, to address issues relating to staffing. We talked with two housekeeping staff. They told is about their previous experience in similar work. They said they had had a good period of induction into their posts lasting three months. We asked them if they had access to doing National Vocational Qualifications (NVQ) and regular supervision. They told us they did not. We talked with registered nurses about induction, they reported that new members of staff worked on a supernumerary basis for several weeks before they started work on their own. They reported that they assigned a new member of staff to work either with themselves or a senior carer and that they had good liaison with the manager about how newly employed staff were progressing. The home has a written induction programme which complies with current guidelines. Induction programmes seen had been fully completed. In their annual quality audit, it was reported that over 50 of care staff are trained to NVQ II or above. Mrs Bulmer and her staff have begun to further develop training programmes since the last inspection and individual staff records have been developed. Training has concentrated on ensuring that all mandatory areas are up to date, although other areas such as audiology have been considered. Training now needs to be further developed with an emphasis on the use of external professionals, rather than DVDs and other distance learning materials. The lack of awareness of the importance of prevention of pressure damage and use of thickening agents indicates that these are areas which need to be addressed. Where training from external professionals does take place, record-keeping needs to be improved. For example an external professional was reported to have trained staff on use of equipment in relation to an individual resident. However there were no records to state which staff members had been trained and although a registered nurse reported that a carer was applying this equipment, Mrs Bulmer was unaware of this. Additionally, on the day of the site visit, two members of staff who reported that they usually worked on a different floor would have had to meet this person’s needs but there was no written evidence that either had been trained in the area although a registered nurse did report that they thought that the carer would know what to do, due to experienced gained outside the home. Given that the resident’s records indicated that they did experience difficulties with this equipment at times, more emphasis in establishing who had been appropriately trained is needed. Relatives commented on whether staff had the right skills to care for people one states “Not all of them – some are very good, others not so good”, another “Just a few of the staff let the side down” and another “Depends on individuals.” A review of records indicated that the home employed at least one enrolled nurse. Such nurses are not trained in medicines administration as part of their training, so they should be assessed in medicines administration on employment and periodically after that. Mrs Bulmer reported that she Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 28 assessed registered nurses on administration of medicines on employment as part of their induction, but this was not supported by records. Considering the issues relating to ill-advised practice in the administration of medicines, documentation and care planning, it is advisable that a system for regular clinical supervision for all registered nurses in administration of medicines be developed. The files of three recently employed people and three longer term employed people were reviewed. These files showed much improvement from the previous inspection. All files now included police and health checks. Two satisfactory references were obtained prior to employment. One person who had not yet come in to post did not have a full employment history. The home continues not to complete interview assessments on peoples’ suitability for their role at interview. If this had taken place for this individual, knowledge about their previous employment record could have been documented. The manager agreed to ensure that a full employment history was obtained for this person, before they were employed. Interview assessment records can also be used to demonstrate that the principals of equal opportunities have been upheld. Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 29 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, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Improvements have been made to systems for management and administration across a range of areas, however a few areas relating to documentation and certain aspects of safety need to be addressed. EVIDENCE: The manager of the home is an experienced manager and registered nurse. Since the last inspection, she has developed practice across a range of areas and has ensured that areas identified have either been addressed or show progress, apart from certain aspects of meeting needs and staffing (see section 6 above). She now needs to ensure that all matters are addressed in full. A detailed improvement plan was submitted following the previous inspection Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 30 and an annual quality assessment was submitted prior to this inspection. The manager has developed the quality audit process, considering a range of matters, including accidents and complaints. Accident records are now fully documented, as well as being audited regularly. Mrs Bulmer was advised that she could consider infection rates as part of this audit. The home is visited regularly by a senior manager, who writes a monthly report. This considers a range of matters and the manager clearly meets with residents on every visit, to receive their opinions on care delivery. The home has different systems for payments of additional items such as chiropody and hairdressing. As noted in standard 1 above, this is not clarified in the service users’ guide. For items such as newspapers and chiropody, people are invoiced monthly by head office, however for items such as hairdressing, payments are made from within the home. The Operations Director reported that this system is being reviewed and that the home are planning in future to invoice monthly for all additional items. Mrs Bulmer has commenced a system for supervision of care staff and records were seen. This system is still in its infancy, with those staff records reviewed showing only one or at the most two supervisions since the last inspection. She reports that she is planning to introduce clinical supervision for registered nurses. Ancillary staff do not yet have supervision. Two domestic staff reported that they did attend regular staff meetings where they could contribute to the agenda. As noted in section 2 above, records relating to resident nursing and care have improved markedly since the last inspection. However some records do need further development. Records need to be completed contemporaneously to ensure that they are accurate, otherwise people may forget or document matters incorrectly (see also section 2 below). A person’s record stated that they had drunk 150mls when their beaker had been filled up to 150mls but most of it had not yet been drunk. Another person when visited mid-morning had records stating that they were sat up in bed, when they were lying on their left side, another person who was visited at 2:00pm had records stating that they were sitting in their chair when they were back in bed. Many records indicated that night staff attended the residents hourly at night, all records indicated that this took place at the same time. With so many people needing attention, it would not be possible for all people to be checked at the same time by the three staff on duty and records should reflect when care was provided. As noted in Section 6 above, the home has concentrated on ensuring that all mandatory training is up to date, including areas such a manual handling, fire safety and infection control. Two cleaners told us that they had received regular training in moving and handling, fire safety, Control of Substances Hazardous to Health, abuse awareness, infection control and food safety. A matrix for training has been drawn up and this can be reviewed to show which Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 31 members of staff need training and in which areas. There are records in place to show that the home is maintained and equipment serviced. There were a number of doors being held open with doorstops. This means that residents in those rooms were not adequately protected in the event of a fire. This matter and the oxygen cylinders notes in Section 2 above, will be reported to the fire safety officer. One of the staff told us that protective clothing, disposable gloves and cleaning materials were allocated to them at each shift. At other times the cupboard was locked. This person reported that they had been trained in infection control. Where residents needed bed safety rails, a revised assessment has been put in place, these reflect guidelines by external agencies such as the Health and Safety Executive. One resident’s documentation stated that they were always to have protection on their safety rails but when they were visited, they were found not to have the protection in use. A member of staff knew why this was and reported that their use had been discontinued. This was not documented in their records, together with how the person was to be protected from the risk of damage to their thin skin. Another person had references to the use of bed safety rails in two different parts of their care plans, these did not reflect each other. Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 32 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 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 X 18 3 3 3 X 3 X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 2 2 2 Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 33 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 OP1 Regulation Requirement Timescale for action 30/06/08 2. OP7 5(1)(b)(d) The summary of the most recent inspection report and terms and conditions of residence must be available in the service users guide. 15(1) Where a service user has or is 30/06/08 known to have a nursing or care need, a full care plan must always be put in place to direct staff on how the need is to be met. Care plans must be precise and direct all staff on actions to take to meet the service user’s needs. Care plans must take into account research-based evidence about how to prevent risk to service users. IN PROGRESS from the last inspection of 25/9/07, not addressed in full. Previous timescale 31/12/07 Monitoring charts for the documentation of provision of frequent care to frail service users must be accurately completed at the time care was provided. All registered nurses must DS0000015897.V358653.R01.S.doc 3. OP8 17(1)(a)S 3(3)(k) 31/05/08 4 OP9 13(2) 31/05/08 Page 34 Cedars Nursing Home (The) Version 5.2 5. OP9 13(3) 6. OP9 13(3) 7. OP9 17(1)(a)S 3(3)(m) 8. OP15 12(1)(a) always perform medicines administration in a safe manner and in accordance with the home’s procedures. Registered nurses must not document that a person has taken their medication until this has taken place. Prescribed items which have been discontinued or which were prescribed for a service user who has died must be safely and separately stored before disposal. Full documentation of such items must be in place. Prompt disposal must be ensured. Where a service user does not take a prescribed item, there must be full records relating to this. Care plans relating to medication must be developed where indicated, this includes medicines prescribed as required, where a resident wishes to self-medicate or where a medicine can have a effect on a service users’ well-being. Where a service user needs support to eat, this must always take place and in a prompt manner. IN PROGRESS from the last inspection of 25/9/07, not addressed in full. Previous timescale 30/11/07 All equipment needed by service users to prevent risk of pressure damage must always be provided, in accordance with the individual’s assessed degree of risk. Where equipment is not provided in accordance with the assessed degree of risk, the reasons why must always be documented. DS0000015897.V358653.R01.S.doc 31/05/08 31/05/08 30/06/08 31/05/08 9. OP22 13(4,c) 31/05/08 Cedars Nursing Home (The) Version 5.2 Page 35 10. OP26 13(3) IN PROGRESS from the last inspection of 25/9/07, not addressed in full. Previous timescale 30/11/07 All sanitary items and items used 31/05/08 in nursing and care must always be maintained at full standards of cleanliness. Equipment provided must be intact, so that it can be properly cleaned and not present a risk of cross infection. IN PROGRESS from the last inspection of 25/9/07, not addressed in full. Previous timescale 30/11/07 A full written review of staffing levels must take place, including a review of service users’ dependency, to ensure that enough staff, with a suitable skill mix are on duty throughout the 24 hour period to ensure that service users’ needs can be met. IN PROGRESS from the last inspection of 25/9/07, not addressed in full. Previous timescale 31/01/08 Service users must not be left unsupervised for extended periods when in the sitting or dining rooms. All staff must be fully trained in areas relating to provision of nursing and care to elderly people. Full records of specific training to meet resident need must be maintained, to ensure that the staff on duty are trained in how to meet such specific needs. Written records must be maintained of assessments in administration of medicines for enrolled nurses. DS0000015897.V358653.R01.S.doc 11. OP27 18(1)(a) 31/05/08 12. OP27 13(4)(c) 31/05/08 13. OP30 18(1)(c) 31/08/08 14. OP30 18(1)(c) 31/05/08 15. OP30 18(1)(c) 31/05/08 Cedars Nursing Home (The) Version 5.2 Page 36 16. OP36 18(2)(a) There must be evidence that all staff have been supervised in their role and that an on-going programme has been put in place to ensure that staff are supervised. 31/08/08 17. OP38 13(7) IN PROGRESS from the last inspection of 25/9/07, not addressed in full. Previous timescale 31/01/08 Where safety rails are being 31/05/08 used, all care plans relating to need must be regularly evaluated. Care plans relating to the use of protection to safety rails must always be complied with. IN PROGRESS from the last inspection of 25/9/07, not addressed in full. Previous timescale 30/11/07. The home must ensure that it regularly reviews hazard notices and guidelines and ensure that relevant risk assessments are drawn up and complied with. N.B this relates to a similar requirement which was identified at the previous inspection. 18. OP38 13(4)(b) 31/05/08 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 OP1 Good Practice Recommendations There should be evidence that the home’s service users’ guide is readily available to all people who would wish to review it. DS0000015897.V358653.R01.S.doc Version 5.2 Page 37 Cedars Nursing Home (The) 2. OP1 The home should revise its statement of purpose and service users’ guide, to fully reflect all matters relating to the services provided by the home. IN PROGRESS from the last inspection of 25/9/07 Staff should be trained to use care plans as working documents, to inform them of individual service users’ needs. Where a service user has a change in dietary requirements, the kitchen staff should be informed, as well as nursing and care staff. All records in the Controlled Drugs Register should be clear. Practice should be reviewed so that service users are not taken to the dining room for an extended period before their meal, unless they wish to do so. The practice of leaving service users in wheelchairs and not transferring them to appropriate chairs when in communal rooms should be reviewed. The practice of mixing all liquidised foods together should be reviewed. Equipment used in service user care should be stored away from the floor and any stained items be disposed of. The interview assessment tool should be used for all prospective staff and show that any discrepancies in application have been considered at that time. NOT ADDRESSED from the last inspection of 25/9/07 All registered nurses’ should have their competencies for administration of medicines regularly assessed and written records maintained. Audits of infection rates and types should be included in the homes’ own quality audit. 3. 4. 5. 6. 7. 8. 9. 10. OP7 OP8 OP9 OP15 OP15 OP15 OP26 OP29 11. 12. OP30 OP33 Cedars Nursing Home (The) DS0000015897.V358653.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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