Inspecting for better lives Random inspection report
Care homes for older people
Name: Address: The Cedars Nursing Home Northlands Landford Salisbury Wiltshire SP5 2EJ The quality rating for this care home is: The rating was made on: one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Susie Stratton Date: 1 4 1 1 2 0 0 8 Information about the care home
Name of care home: Address: The Cedars Nursing Home Northlands Landford Salisbury Wiltshire SP5 2EJ 01794390284 01794390068 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Alphacare Holdings Limited care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability 4 0 4 Over 65 0 40 0 Conditions of registration: The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) maximum of 4 places Physical Disability (Code PD) - maximum of 4 places Old age, not falling within any other category (Code OP) - maximum of 40 places The maximum number of service users that can be accommodated is 40. Date of last inspection Brief description of the care home The Cedars Nursing Home is registered to provide nursing care for 40 people. The home is a recently-completed purpose-built building, situated in rural location on the Care Homes for Older People Page 2 of 14 A36 mid-way between Salisbury and Southampton. Accommodation is provided over two floors with a passenger lift in-between. All of the rooms are single and provide modern, comfortable accommodation. The home has large surrounding grounds and pleasant views of the countryside. Currently an older building attached to the home is being fully refurbished. There is car parking on site and a bus stop at the end of the drive. 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. Care Homes for Older People Page 3 of 14 What we found:
This random inspection of the Cedars was performed on Friday 14th November 2008 between 9:30am and 3:30pm. The inspection was performed by a regulation inspector and a pharmacist inspector. Throughout the inspection, they are referred to as we because the inspection is being performed on behalf of the Commission for Social Care Inspection. This random inspection was carried out to review progress towards meeting requirements which had been set in the previous inspections of 25/09/07 and 11/04/08, specifically those relating to practice in administration of medication, provision of nursing and care to frail people, people with dementia care needs, and staff training. At this inspection, we met with eight frail residents and reviewed six peoples records. These residents all spent most of their time either in bed or in their rooms, some of them had additional needs relating to dementia. Most of these residents found communication complex. We reviewed systems for storage of medication, records relating to medication, a medicines administration round and care plans relating to medication needs. We looked at seven staff records, including training records. One of the members of staff had recently been employed. What the care home does well:
One person reported these beds are very, very comfortable and was able to describe some of the care they needed. Another person reported I spend all my time in bed. One person with dementia care needs was observed to exhibit some complex noisy behaviours for a period during the inspection, however this did not continue for an extended period of time and staff spoken with knew the reasons why the person showed these noisy behaviours. At this inspection, we looked at care plans for six of the people we met with. The home has put much effort into improving care plans and ensuring that they are individualised in tone. Care plans reviewed, documented a wide range of nursing and care needs relating to the person. Residents with additional dementia care needs had care plans about their dementia care needs. Their care plans detailed how staff were to meet the peoples needs. Such care plans were written in an individualistic manner and used clear, non-judgemental language. All of the people considered in detail were assessed as being at risk of developing pressure ulcers. All of them either had a care plan about how risk was to be reduced and/or had reference made to how risk was to be reduced in other care plans. The eight frail people met with were not able to reliably change their positions or give themselves food or fluids independently. To ensure that such people have their needs met, the home uses a monitoring chart to document that such frail people have their positions changed regularly and were given drinks and meals. At this inspection, most of the residents were provided with appropriate pressure relieving equipment, which was consistent with their assessed degree of risk and Care Homes for Older People
Page 4 of 14 National Institute for Clinical Excellence (NICE) guidelines. All residents who had wounds had care plans relating to the wound, together with an evaluation record, so that the response of the wound to treatment could be assessed. All wounds were photographed at various intervals. All medicines were stored securely and appropriately. Records were kept of all medicines received into the home and sent for disposal. Some of the medicines charts had very clear instructions on them for specific doses or more complex dosage regimes. All creams and lotions were labelled and signed for when given. We saw medication being given in a safe and considerate way to people in the home. Staff records showed that staff are trained in mandatory areas relating to such matters as manual handling and fire safety. Records showed that training is being progressed to support staff in meeting residents needs, in areas such as dementia care and prevention of pressure damage. The manager showed us how medication training and supervision had been used to reinforce good practice in the nursing staff. What they could do better:
At the inspection of 25/09/07, it was required that where a person had or was known to have a nursing or care need, that a full care plan must always be put in place to direct staff on how the persons needs were to be met. Care plans were required to be precise and direct staff on actions to take to meet the persons needs. Care plans were also required to take into account research-based evidence about how to prevent risk to residents. By the previous inspection of 11/04/08, progress was noted to have been made, but the requirement had not been addressed in full. The NICE guidelines, the European Pressure Ulcer Advisory Panel (EPUAP) and local guidelines all state where a person is assessed as being at risk of pressure ulcers, that as well as providing pressure relieving aids, in order to prevent risk of pressure ulcers, people at risk also need to have their positions changed at least four hourly and for those people at higher risk, they need their positions changing two hourly. The guidelines also state that if a person has pressure ulceration that time sitting out of bed needs to be limited to two hours. Only one of the six persons care plans stated how often their position was to be changed. This persons care plan stated that their position was to be changed two to three hourly. A review their monitoring charts for the days before this inspection did not provide evidence that their position had been changed at this frequency. This is of concern, as the person was admitted to the home with existing pressure ulceration. One resident who was assessed as being at very high risk of pressure ulcers had two plans which stated how their risk was to be reduced. One of these plans stated that the person was to have their pressure areas inspected daily and neither plan stated how often staff were to change this persons position. This does not conform to NICE or EPUAP guidelines. Two of the people met with had increased risk or actual pressure ulceration to their heels. Their care plans for prevention of pressure damage did not state how the risk to their heels was to be reduced. We looked at the monitoring charts at different times of the day for all these people Care Homes for Older People Page 5 of 14 and also reviewed monitoring charts for these people for previous days. A review of monitoring charts for previous days did not provide evidence that any of the people had had their positions changed at the frequency indicated by their assessed risk of pressure ulcers, in accordance with NICE or EPUAD guidelines. For example one persons records did not document that, their position had been changed between 18:00 and 9:00 the following day. One person with existing pressure ulceration was observed to be out of bed for more than two hours. At the inspection of 25/09/07, it was required that all equipment needed by residents to prevent risk of pressure damage must always be provided, in accordance with the individuals assessed degree of risk. It was required that where equipment is not provided in accordance with the assessed degree of risk, the reasons why must always be documented. This was noted to be in progress at the previous inspection of 11/04/08 but it had not been addressed in full. NICE guidelines state types of equipment needed to prevent pressure ulcers, according to the persons assessed degree of risk. One resident who was assessed as being at very high risk of pressure ulcers was sitting on a chair on which a domestic-style cushion had been placed. The reasons for this were not documented in their care plan relating to prevention of risk of pressure ulcers and when we asked a carer, they did not know why the person was not provided with an appropriate pressure relieving cushion. Past records showed that two people had only been provided with pressure relieving equipment consistent with their assessed degree of risk, a period after they had been assessed as begin at very high risk of pressure ulcers. Improvements are advisable in the detail of documentation relating to wound management, as the evaluations of wounds did not document standard measurable criteria, such as precise measurements of size, presence of pain or evidence of infection, every time the dressing was changed, as is standard practice. One of the residents was reported to have an infection, the actions to be taken in the light of this were not documented in their care plan. Two of the people met with had urinary catheters. One resident had the clinical indicator for their catheter documented, as is advised but another person did not. This persons records indicated a history of urine infections. Urinary catheters have been identified as a factor in urinary infections, so it is advisable that the clinical need for use of a catheter be actively considered in care plans. One resident had an appliance in their room, which they told us about. They reported on how long they were meant to wear this appliance each day. There were no instructions in the persons care plan to direct staff on how they were to help the resident with the fitting and use of the appliance. Staff confirmed with us that the person, and their care plan documented, that the person was confused at times and so would not always be able to reliably inform staff as to how their appliance was to be used. At the previous inspection of 11/04/08, it was required that monitoring charts for the documentation of provision of care to frail service users must be accurately completed, at the time care was provided. Unlike the charts for the previous days, the charts for the day of our visit did indicate that peoples positions were being changed and that they were given fluids. However many of the charts continued not to be completed at the time care was given. For example, we were visiting a resident at 10:00 and a care Care Homes for Older People Page 6 of 14 assistant came in and completed their chart from 8:00 onwards, including a record that the person had drunk 200mls at 8:00. One resident visited at 10:30 was observed to be on their left side in bed, their chart stated that they had been turned at 10:15am to their right side. One resident who was observed at 9:45, 12:30 and 13:30 to be on their right side had no record of their position in bed, apart from a record stating that they had been sat up at 11:50. One person who was visited at 11:00 had no record of changes of position, then at 12:30 was noted to have had a record made stating PAS at 10:50. British Standard signage is needed to show where oxygen cyliners are in use or stored, for example clinical rooms or rooms where oxygen cyliners are stored. The fridge temperature is monitored but the readings show that it has recently been lower than the required 2c-8c. Medication administration records are written by the nursing staff and signed by the doctor who visits regularly. There were some charts where inaccuracies were seen. The medication for two people was labelled to be taken regularly, however on the chart is was written as when required and was not recorded as being given regularly. Another medicine had the wrong strength written on the chart. The care plans that we checked did not make reference to the medicines that were prescribed as required. Medicines prescribed in this way must have clear guidelines as to their use, so that they can be given consistently in accordance with the prescribers instructions. One recently employed care assistant had no written evidence of an induction on their file. It was reported that the person was experienced in their role and that they had been allocated to a more senior member of staff as a mentor when they started their employment. All staff, even if they are experienced in their role will need to be fully inducted, so that they are aware of the homes policies and procedures, as well as ensuring that they understand the general principals. Written records are needed of induction, so that they can be referred to at a later date, for example during supervision or appraisal. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 7 of 14 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set.
No. Standard Regulation Requirement Timescale for action 1 1 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. Not reviewed at this inspection. 30/06/2008 2 7 15(1) Where a service user has or 30/06/2008 is 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. Continues to be IN PROGRESS from the inspection of 25/9/07, not addressed in full. Previous timescale 31/12/07 3 8 17(1)(a)S3(3) Monitoring charts for the (k) documentation of provision of frequent care to frail service users must be accurately completed at the time care was provided. 31/05/2008 Care Homes for Older People Page 8 of 14 IN PROGRESS from the last inspection. Previous timescale was 31/5/08 4 9 17(1)(a)S3(3) Care plans relating to (m) 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 wellbeing. IN PROGRESS from the last inspection, previous timescale 30/6/08 30/06/2008 5 15 12(1)(a) 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. Not reviewed at this inspection. 31/05/2008 6 26 13(3) 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. IN PROGRESS from the last inspection of 25/9/07, not addressed in full. Previous timescale 30/11/07. Not reviewed at this inspection. 31/05/2008 7 27 18(1)(a) A full written review of staffing levels must take 31/05/2008 Care Homes for Older People Page 9 of 14 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. Not reviewed at this inspection. 8 27 13(4)(c) Service users must not be left unsupervised for extended periods when in the sitting or dining rooms. Not reviewed at this inspection. 31/05/2008 9 30 18(1)(c) All staff must be fully trained 31/08/2008 in areas relating to provision of nursing and care to elderly people. IN PROGRESS from inspection of 11/4/08 10 30 18(1)(c) Full records of specific 31/05/2008 training to meet resident need must be maintained, to ensure that the staff on duty are trained in how to meet such specific needs. IN PROGRESS from last inspection. 11 36 18(2)(a) There must be evidence that 31/08/2008 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.
Page 10 of 14 Care Homes for Older People IN PROGRESS from the last inspection of 25/9/07, not addressed in full. Previous timescale 31/01/08. Not reviewed at this inspection. 12 38 13(4)(b) 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. Not reviewed at this inspection. 31/05/2008 13 38 13(7) Where safety rails are being 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. Not reviewed at this inspection. 31/05/2008 Care Homes for Older People Page 11 of 14 Requirements and recommendations from this inspection
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 9 13 Fridges for medication storage must be kept between 2c and 8c. This ensures that all medicines are stored at their optimum temperature and are suitable for use 05/02/2009 2 9 13 Medication administration records must accurately state the prescribed instructions of each medicine. This will ensure that all medicines are given in accordance with the prescribers instructions. 05/02/2009 3 9 13 British Standard signage 05/02/2009 must always be used on doors of rooms where oxygen cylinders are used or stored. This is to properly advise people in the event of a fire. 4 30 18 There must be written evidence that all staff have been given a structured induction programme. 05/02/2009 Care Homes for Older People Page 12 of 14 Residents need to have care provided to them by staff who are fully aware of their responsibilities and the homes policies and procedures. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No. Refer to Standard Good Practice Recommendations 1 2 8 8 Where a resident uses a urinary catheter, the clinical reason for its use should always be documented. Where a resident has an infection, an assessment of risk of this infection should be completed and directives included in their care plan as to how risk of spread of infection is to be reduced. Evaluations of wounds should include measurable criteria, such as precise measurements of size, presence of pain or evidence of infection. 3 8 Care Homes for Older People Page 13 of 14 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 14 of 14 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
