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Inspection on 25/09/07 for The Cedars Nursing Home

Also see our care home review for The Cedars Nursing Home for more information

This inspection was carried out on 25th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Cedars is a large, attractive country house, with well kept, spacious gardens in a quiet, rural area. All the rooms are different from each other and they all exceed minimum standards for size; these two factors make them easier for residents and their families to personalise. The home has an extensive and varied activities programme and enthusiastic activities staff. A stable staff team are employed, some of whom have worked there for many years. Staff support the home and each other, so that agency staff are not used. People expressed their appreciation of the home. One person reported "It`s a lovely big house", another "It`s marvellous here" and another "I like it very much". People also expressed their appreciation of the staff. One person described staff as "very amiable and helpful" another person reported "The girls are excellent and I`m good friends with all of them" and another reported on how staff "do listen"

What has improved since the last inspection?

At the last inspection, six requirements and two good practice recommendations were made. Four of the six requirements had been addressed and both of the good practice recommendations. Care plans are now commenced when people are admitted to the home. The medication reference manual is up-to-date. A clearer record for recording the administration of medication has been developed. Stained bedroom carpets have been cleaned. One specified bedroom window has been repaired. Care plan training has been provided to staff.

What the care home could do better:

Twenty requirements, two of which were un-met from the previous inspection and fourteen good practice recommendations were identified at this inspection. The home must ensure that all residents have full assessments of their needs, including assessment of risk of pressure damage and falls. Where a resident been assessed as having a need or a risk or is known to have a nursing or care need, a care plan must always be put in place to direct staff on how risk is to be reduced and their individual nursing and care needs met. Assessments and care plans must be reviewed monthly or when a resident`s condition changes. This is an un-met requirement from the previous inspection of 5th July 2006. Care plans must be precise, measurable and direct all staff on actions to take to meet the person`s needs. Where a person is unable to or needs support in moving themselves or taking in an adequate diet or fluids, a monitoring record must be put in place, so that staff can ensure that the needs of these frail people are being met. Where a service user`s fluid intake is monitored by use of a fluid chart, the amount of fluids taken in every 24 hours should be totalled. Where a resident`s GP or an external healthcare professional makes directives, there must be written evidence that these directives have been carried out, or if they have not been carried out, the reason why this is. Care plans relating to wound care should direct staff on how often a wound`s progress to treatment is to be assessed. There must be clear records of the circumstances of any accident to a service user. Accident records should be completed by the person who first observed the accident, not a third party. The safety of staff and residents must not be compromised by the use of inappropriate blood testing devices. Recent information from the Medicines and Healthcare Regulatory Agency (MHRA) must be actioned. All medicines and dosages (including oxygen) must be listed on the medication administration record. Risk assessments for self administration should cover the method of management of the medicines by the individual resident and be regularlyreviewed. Medicines which have a shortened expiry date after opening should be dated when first opened. Where a resident needs support to eat, this must always be given in a prompt manner. When assisting residents to eat, staff should be able to maximise opportunities, to ensure that the mealtime can be made a pleasant, social occasion. Improved systems for delivering meals promptly and in a safe manner to residents should be considered. The divan beds currently in use for people with nursing needs must be replaced with an appropriate bed suitable to meeting the nursing and care needs of people. This is unmet from the previous inspection of 5th July 2007. All equipment needed by residents to prevent risk of pressure damage must always be provided, in accordance with the person`s assessed degree of risk. Where equipment is not provided, the reasons why must always be documented. All equipment must be correctly used in accordance with manufacturer`s instructions. All sanitary items and items used in nursing and care must always be clean. Equipment provided must be intact, so that it can be properly cleaned and not present a risk to cross infection. Where safety rails are being used, assessment of need and care plans should always be drawn up. These must be regularly evaluated. Care plans relating to the use of protection to safety rails must always be complied with by staff. A copy of the Medicines and Healthcare Regulatory Agency (MHRA) and Health and Safety Executive`s directives on the use of safety rails should be obtained and considered when developing documentation relating to safety rail assessments. A full written review of staffing levels must take place, including a review of residents` dependency, to ensure that enough staff, with a suitable skill mix are on duty throughout the 24 hour period, to ensure that residents` needs can be met. No staff must be employed until all checks relating to their suitability have taken place and full evidence retained on their file. This must include past working history, two suitable references and evidence that they are able to work. Photographs of staff in employment records should be clear, so that they can fully verify proof of identity. The interview assessment tool should be used for all prospective staff and show that any discrepancies in application have been considered at that time. Training records should be reviewed and fully up-dated, to provide full evidence of training participated in by staff. All staff must be trained in their individual responsibilities for prevention of spread of infection. There should be evidence that staff have been trained in the range of medical conditions commonly experienced by older people. 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

CARE HOMES FOR OLDER PEOPLE Cedars Nursing Home (The) Northlands Landford Salisbury Wiltshire SP5 2EJ Lead Inspector Susie Stratton Unannounced Inspection 10:00 25 September 2007 th 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.V345290.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.V345290.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.V345290.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 5th July 2006 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 first site visit, there were 28 persons resident in the home and no empty beds, as some double rooms were being used by single occupants. The Cedars is owned by Alphacare 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 £520 to £895 per week. Additional costs include chiropody, hairdressing, newspapers and sundries, such as toiletries. All people are given a copy of the service users’ guide on admission. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. As part of the inspection, questionnaires were sent out to residents and their relatives and 10 were returned. Comments made by residents and their relatives in questionnaires and during the inspection process have been included when drawing up the report. An annual quality assurance assessment was submitted by the home prior to this inspection. This document provided information to support the inspection. As The Cedars is a larger registration, the site visits took place over three days, on Tuesday 25th September 2007 between 9:50am and 4:00pm, on Thursday 27th September 2007 by the pharmacist inspector as part of their random process for inspecting homes and Wednesday 10th October 2007 between 9:15am and 12:20pm. The manager, Mrs Bulmer was on duty for all of the site visits. During the site visits, we met with eleven residents and observed care for five further residents for whom communication was difficult. We reviewed care provision and documentation in detail for seven residents. As well as meeting with residents, we met with three registered nurses, four carers, an activities coordinator, a chef, a catering assistant, the maintenance man, a domestic, a laundress and the administrator. We toured all the building and observed the lunch-time meal and two activities sessions. We observed systems for administration of medicines. 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, attractive country house, with well kept, spacious gardens in a quiet, rural area. All the rooms are different from each other and they all exceed minimum standards for size; these two factors make them easier for residents and their families to personalise. The home has an extensive and varied activities programme and enthusiastic activities staff. A stable staff team are employed, some of whom have worked there for many years. Staff support the home and each other, so that agency staff are not used. People expressed their appreciation of the home. One person reported “It’s a lovely big house”, another “It’s marvellous here” and another “I like it very much”. People also expressed their appreciation of the staff. One person Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 6 described staff as “very amiable and helpful” another person reported “The girls are excellent and I’m good friends with all of them” and another reported on how staff “do listen” What has improved since the last inspection? What they could do better: Twenty requirements, two of which were un-met from the previous inspection and fourteen good practice recommendations were identified at this inspection. The home must ensure that all residents have full assessments of their needs, including assessment of risk of pressure damage and falls. Where a resident been assessed as having a need or a risk or is known to have a nursing or care need, a care plan must always be put in place to direct staff on how risk is to be reduced and their individual nursing and care needs met. Assessments and care plans must be reviewed monthly or when a resident’s condition changes. This is an un-met requirement from the previous inspection of 5th July 2006. Care plans must be precise, measurable and direct all staff on actions to take to meet the person’s needs. Where a person is unable to or needs support in moving themselves or taking in an adequate diet or fluids, a monitoring record must be put in place, so that staff can ensure that the needs of these frail people are being met. Where a service user’s fluid intake is monitored by use of a fluid chart, the amount of fluids taken in every 24 hours should be totalled. Where a resident’s GP or an external healthcare professional makes directives, there must be written evidence that these directives have been carried out, or if they have not been carried out, the reason why this is. Care plans relating to wound care should direct staff on how often a wound’s progress to treatment is to be assessed. There must be clear records of the circumstances of any accident to a service user. Accident records should be completed by the person who first observed the accident, not a third party. The safety of staff and residents must not be compromised by the use of inappropriate blood testing devices. Recent information from the Medicines and Healthcare Regulatory Agency (MHRA) must be actioned. All medicines and dosages (including oxygen) must be listed on the medication administration record. Risk assessments for self administration should cover the method of management of the medicines by the individual resident and be regularly Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 7 reviewed. Medicines which have a shortened expiry date after opening should be dated when first opened. Where a resident needs support to eat, this must always be given in a prompt manner. When assisting residents to eat, staff should be able to maximise opportunities, to ensure that the mealtime can be made a pleasant, social occasion. Improved systems for delivering meals promptly and in a safe manner to residents should be considered. The divan beds currently in use for people with nursing needs must be replaced with an appropriate bed suitable to meeting the nursing and care needs of people. This is unmet from the previous inspection of 5th July 2007. All equipment needed by residents to prevent risk of pressure damage must always be provided, in accordance with the person’s assessed degree of risk. Where equipment is not provided, the reasons why must always be documented. All equipment must be correctly used in accordance with manufacturer’s instructions. All sanitary items and items used in nursing and care must always be clean. Equipment provided must be intact, so that it can be properly cleaned and not present a risk to cross infection. Where safety rails are being used, assessment of need and care plans should always be drawn up. These must be regularly evaluated. Care plans relating to the use of protection to safety rails must always be complied with by staff. A copy of the Medicines and Healthcare Regulatory Agency (MHRA) and Health and Safety Executive’s directives on the use of safety rails should be obtained and considered when developing documentation relating to safety rail assessments. A full written review of staffing levels must take place, including a review of residents’ dependency, to ensure that enough staff, with a suitable skill mix are on duty throughout the 24 hour period, to ensure that residents’ needs can be met. No staff must be employed until all checks relating to their suitability have taken place and full evidence retained on their file. This must include past working history, two suitable references and evidence that they are able to work. Photographs of staff in employment records should be clear, so that they can fully verify proof of identity. The interview assessment tool should be used for all prospective staff and show that any discrepancies in application have been considered at that time. Training records should be reviewed and fully up-dated, to provide full evidence of training participated in by staff. All staff must be trained in their individual responsibilities for prevention of spread of infection. There should be evidence that staff have been trained in the range of medical conditions commonly experienced by older people. 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. Managers of the home must implement their own system for reviewing quality of service, in order to ensure that all requirements are addressed within timescales and regulations met. Monthly visits by a manager should consider progress in requirements and recommendations identified during the inspection process. A record of all informal concerns raised with staff and actions taken should be maintained. The home should revise its statement of purpose, to Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 8 fully reflect the types of people admitted and how they can meet their needs, including details of staff number and skill mix available on each shift. 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.V345290.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.V345290.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 home does not admit people for intermediate care, so 6 is N/A Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Prospective residents are given information about the services offered and have a full assessment of need carried out, so that the home can assure all involved that they can meet their needs. EVIDENCE: All people are given a copy of the service users’ guide prior to admission, to inform them of the services offered. Of the nine people who responded to this section of the questionnaire, eight reported that they had received enough information about the home prior to admission. One person reported “My daughter came and inspected the Cedars Nursing home” another person described the information as “quite straight forward and informative” and one person reported that they lived near the home and had visited people in the home before their admission and so knew all about it. The information provided is clear and complies with regulations and guidelines. As the home Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 11 admits people for terminal care and people with complex needs, it is advisable that they set out how they are able to care for people with such needs in the statement of purpose. It is also advisable that it details how many staff and their skill mix on each shift, to fully inform people. In the annual quality assessment, the manager reported that one of the areas they felt they did well was to ensure all groups are catered for in their social, cultural and religious preferences. The manager or her delegate sees all prospective residents prior to admission and performs a comprehensive assessment of their needs. Records seen were clear and completed in full, reflecting what was observed and what the person reported. Where additional information was required, for example from the Parkinson’s Nurse, this was obtained. The home considers individual person’s needs at admission, for example, one person was supported in bringing in their pet bird with them on admission which their relative reported was much appreciated. The manager reported that, when considering a prospective resident for admission, she considers the staffing of the home and dependency of residents currently in the home, to ensure that they can meet the needs of all residents, if the person is admitted. Cedars Nursing Home (The) DS0000015897.V345290.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 poor. This judgement has been made using available evidence, including visits to this service. People are not consistently supported by the home’s systems for meeting their medical, nursing and care needs; this could put frail people and those with complex needs, at risk. The home has procedures for the handling of medicines which protect the residents; however some records need to be more complete to ensure safe practice. EVIDENCE: The home is continuing to introduce new documentation relating to assessment of need and care plans, to direct staff on how needs are to be met. While progress has been made, the home needs to further develop its systems, to ensure that all residents’ needs are assessed and care plans developed where relevant. In their annual quality assessment, the manager reported that she was aware that the home needed to develop more risk assessments; she also reported that they wished to promote independence for residents. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 13 All residents have manual handling assessments completed, together with a care plan. These clearly direct actions to be taken to meet residents’ needs. Most residents have assessments of pressure damage, but not all. This is of concern, as one of the residents who did not have an assessment of risk of pressure damage was likely to be at risk. Where assessments of pressure damage had been made, not all had been evaluated regularly, including when a person’s condition had changed and so risk increased. None of the people who were assessed as being at risk of pressure damage had care plans drawn up to direct staff on how the assessed risk was to be reduced, although some people had some mention of action to be taken to reduce risk in other parts of their care plans. There is an inconsistent approach to prevention of pressure damage, with some people being provided with some equipment which was consistent with their risk, but others not being provided with relevant equipment. One person who was assessed as being at high risk of pressure damage was not provided with any equipment to prevent pressure damage. Some of the people at high risk of pressure damage could not move themselves independently but the home had no monitoring system to ensure that these people were protected by having their positions changed on a regular basis. One person who did not have a care plan about pressure damage had regular references in their daily records to reddened pressure points. Several of the residents’ admission assessments and daily records after admission showed that they were at risk of falls. None of these people had had an assessment of risk of falling from their medical conditions or the home environment and only one of them had a care plan to direct staff on how risk of falls was to be reduced. This care plan stated that the person needed regular checks, but there was no evidence in the form of a monitoring chart or documentation in the person’s daily record, that this was taking place. Falls were documented in residents’ daily records but there was no monitoring records for falls, to assist in staff in analysing the frequency and extent of falls, to inform develop care plans. By the second site visit by our nurse inspector, falls risk assessments and care plans to prevent risk of falls were being developed. Residents are assessed for dietary risk and care plans are put in place where the person is assessed as being at risk. One person’s daily record stated that fluids were to be encouraged but a monitoring system had not been put in place to ensure that the person was taking in adequate fluids. Where a person was not able to assist themselves to eat or drink or was reluctant to eat or drink, there were no monitoring systems to assess if the person was taking in adequate diet and/or fluids during the 24 hour period. This is necessary as the home needs to be in a position to assess if such frail people are receiving the nutritional supports that they need to maintain their health. By the second site visit by our nurse inspector, monitoring systems for fluid intake for frail people were in place. These were not being totalled every 24 hours, as is advised. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 14 Several residents who had difficulty with communication had not been left with their call bells. There were no risk assessments in their records relating to this and it was not clear how their safety would be ensured if they could not use or access the call bell system. Some care plans were clear, for example many care plans relating to continence described how the person’s needs were to be met, including the types of aids and when they were to be used. Night care plans were also very clear and included significant areas for the person such as when they preferred to retire and be offered a morning drink. There was a lack of consistency in some care plans, for example for some people the topical applications to be used to protect tissue viability were clear but for others, although topical applications were in their room and clearly being used, there were no care plans to direct staff on actions to take. Other care plans were not clear, for example one person had a care plan relating to a prolapse, but the directions on actions to take to reduce the prolapse would not direct a person unfamiliar with the resident of what actions needed to be performed and what level of staff should perform this invasive procedure. Another person had a care plan about their behaviours which stated what their behaviours were but there were no directions on interventions or monitoring systems to be used to meet this person’s need. Some people did not have care plans where needs existed. For example, one resident’s daily records made frequent references to the use of ice packs but there was no care plan about where the ice packs were to be applied or indications for their use. Another resident was wearing a continence aid but a continence assessment had not been carried out and there was no care plan about their continence needs. Two members of staff reported that a resident needed particular supports at mealtimes but a care plan had not been put in place and it was observed at lunch-time that this person did not receive the supports that they were reported to need. At the previous inspection, it was required that all care plans be evaluated monthly. At this inspection, it was observed that one resident’s care plan had been regularly evaluated when their nursing and care needs changed. However this had not taken place for other residents and some residents with complex needs had not had their care plans evaluated for over three months. Care plans must be evaluated and up-dated when care needs change, to direct staff on further actions to take to meet need. Care plans also need to be evaluated regularly, to verify that they continue to direct staff on how needs are to be met. Where residents had wounds, the home maintains standard documentation systems to ensure that there are directions on how the wound is to be treated and the frequency of dressing regime. There does not appear to be a standard system for assessing the wound’s response to treatment and this is recommended, as wounds need to be assessed regularly to ensure that they are responding effectively to treatment. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 15 The home has close working relationships with GPs, who staff reported attend the home on a regular basis and will also attend in an emergency. This was supported by records. Of the ten people who responded to this section of the questionnaire all of them reported that they received the medical support that they needed. One person reported “You bet they get the doctor in if you’re not well”. Reviews of records showed that GPs and other healthcare professionals were happy to document in the home’s records, thus ensuring that all people who needed, had ready access to medical directives. For one person, their GP had requested that fluids be encouraged to prevent risk of dehydration, however their care plan had not been amended to reflect this and a fluid balance chart had not been commenced to assess if the individual was taking in adequate fluids. For another person, a specialist nurse had requested a certain intervention relating to their dietary needs and the introduction of a monitoring system in August 2007. Their care plan had not been amended in the light of this and no monitoring system had been put in place. There was some verbal knowledge as to why this was, but this had not been documented in the person’s records. By the second site visit by our nurse inspector, parts of this person’s care plan had been amended. We looked at arrangements for the handling of medicines. Medication administration records are signed by the doctor and changes are also confirmed by doctors’ signatures. Administrations are signed or coded appropriately. Records are kept of all medicines ordered, received and sent for disposal. A procedure is in place to promote safe handling of medicines during administration. Storage is appropriate and controlled drugs are stored and recorded suitably. Residents are supported to manage their own medicines where appropriate and a risk assessment is done. The risk assessments should be more individual to the residents as the medicines are managed in different ways and review dates should be clearly noted. Blood monitoring equipment in use in the home did not comply with recent safety guidelines from the Medicines and Healthcare Regulatory Authority. Oxygen used in the home. Doctors’ records stated the dose but this was not on the medication administration record. All required medicines were in stock. One liquid with a short expiry date after opening had not been dated which would make it difficult to know when it had expired. All personal care was performed behind closed doors. One person reported “I get an all over wash every day and a bath once or twice a week.” Care plans documented how each resident wished to be addressed by staff. Staff such as the kitchen assistant were observed to call residents by their preferred names. The activities coordinator reported that staff were very good at informing her of when residents had been admitted or when a resident’s conditions had changed, so that she could revise her plans on how to meet residents’ needs. The laundress reported that all residents’ clothes were marked, so that they could be promptly returned to them. These were very few unidentified clothes observed and the laundress had put systems in place to identify the owners of these clothes. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence, including visits to this service. Residents are generally supported to live the life that they choose, with an emphasis on provision of a range of activities and supports for choice, particularly at mealtimes. However some areas relating to support from staff, particularly at mealtimes need to be further developed. EVIDENCE: The home provides a varied activities programme, Monday to Friday, run by different activities coordinators, who specialise in different areas. A weekly activities programme is available and residents reported that they could decide if they wished to join in or not, depending on what was being offered. Of the ten people who responded to this section of the questionnaire, eight reported that there were always, one usually and one sometimes, activities arranged by the home that they could take part in. One person reported that they “Enjoy all the activities”. One person commented on the art class, another on “making things” and another on the singing. Residents’ art-work was displayed, together with photographs of social events, such as the fete. One of the activities coordinators was running a group discussion on the morning of the Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 17 first site visit and providing 1:1 activities in the afternoon for those people who were unable or did not wish to leave their rooms. On the third site visit, the other activities coordinator was leading a busy group in the dining room. It was well-attended and lively. The hairdresser was visiting on the morning of the first site visit. All residents have an activities profile on file. Those that were completed were completed to a very high standard and were highly individual in tone. It was clear that as more relevant information was identified, this was added. Profiles included details on residents’ religious observance and its importance to them. Not all profiles were up-to-date. The activities coordinator reported that she had had some time off recently and was working on developing profiles for all newly admitted residents. The activities coordinator will take people out of the home, for example to a local garden centre or push them in a wheelchair down to a local beauty spot. Residents also go out of the home if they wish. One person reported on how they went out regularly with their family. Visitors are encouraged, one person reported “My visitors come and go when they want” another person reported that they appreciated how their relatives could eat with them if they wanted to. A review of residents’ files indicated that relatives were contacted when needed, for example if a person’s condition changed or if they had fallen. Residents reported that they could choose how they spent their days. One person reported “I can do what I want to and am not made to do what I do not want to do”, another person reported that they could eat in their room if they liked and another that they could attend activities that they wished to. Several residents had brought in a range of their own furniture and personal items, making their rooms highly individual in tone, reflecting their likes and preferences. The Cedars has a dining room on the ground floor and residents can also have their meals in their own room if they prefer. The manager reported in her annual quality audit that they had re-opened the dining room in the evening for the residents who wished to eat there in the evening. Of the ten people who responded to this section of the questionnaire, six reported they always, three usually and one sometimes liked the meals. As would be expected in a large home, there was a range of comments about the meals, these varied from “The standard of the food is not always very good”, through “I think they’re quite good” to “The meals are the best part”. Several people commented on the choice and one person reported “I wasn’t well recently and the kitchen did something special that I asked for”. The chef showed a detailed knowledge of residents’ needs for special diets, their individual preferences and any allergies. One lunch-time meal was observed. Meals are taken from the kitchen to residents on trays; sometimes several meals were included on trays. This is a Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 18 time consuming process and may present a manual handling risk to staff and a risk of residents not receiving their preferred meal. This system should be reviewed. It was observed that residents were given a choice of different drinks with their meals. It was noted that very little food was rejected or left. Only five people needed a pureed diet, which is low for a home of this size. As much as possible, residents are encouraged to be independent at mealtimes, with appropriate aids being provided. Where residents needed support to eat, staff were generally available. However it was observed that a member of staff stood up to assist someone to eat their lunch in the dining room and was not supporting the person by eye contact or engaging them in conversation. This was because she was the only carer in the room and had to observe all other residents in case they needed assistance. Meals are social occasions, so if a person needs support, the member of staff should be able to sit with them and encourage conversation. Enough staff need to be provided at mealtimes to ensure that this can happen. One person was known by at least two members of staff to sometimes need support to eat their meal. This person was observed to have a meal put in front of them but no-one returned to check up if the person was eating. This was because staff were busy throughout this time, attending to other residents. Twenty minutes later, the manager happened to go past the person’s room and observe that they had not commenced their meal. She gave the person the support that they needed to eat their meal, however it was no longer warm. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence, including visits to this service. Residents are safeguarded by the home’s systems for investigation of complaints. However inadequate systems for recruitment and ensuring that residents health and personal care needs are met, has the potential to put vulnerable people at risk. EVIDENCE: The Cedars has a complaints policy, which is available in the service users’ guide and is displayed in the front entrance hall. Of the nine people who responded to this section of the questionnaire, all reported that they knew how to make a complaint. One person reported “I would speak to the carer and she would talk to the person in charge”, another “I would speak to one of the sisters in blue” and another “Matron – go straight to the top”. No formal complaints have been received by the CSCI since the last inspection. The manager reported that she often deals with matters brought up by residents and their supporters and considers that because she deals with such matters promptly, that no formal complaints had been received. She was advised that in order to provide evidence of this good practice, she should maintain records of such matters and how they have been dealt with. Staff who have such matters reported to them should do the same. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 20 The home has a very clear policy on safeguarding vulnerable people. All staff spoken with, including the laundress and domestics reported that they had been regularly trained in safeguarding adults. This was supported by records. One matter had been reported via local safeguarding adults since the previous inspection, this was investigated and the home was not identified to be at fault. Residents are not protected by the home’s systems for recruitment of staff (see standard 29 below), as they are not ensuring that they have full information on a wide range of matters relating to prospective member of staffs’ fitness to be employed, prior to giving them employment. The home therefore cannot ensure that some staff are suitable for their roles. Issues relating to health and personal care, particularly in relation to prevention of pressure damage and monitoring the conditions of vulnerable people (see standards 7 and 8 above) could mean that systems are not in place to fully safeguard vulnerable people. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 21 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, 22 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to this service. People reported that they liked the building and facilities. However people could be put at risk by a lack of supply of some equipment to support disabled people and prevent risk and inadequate standards in certain areas to prevent risk of cross infection. EVIDENCE: The Cedars is an older building, which has been up-graded in parts by previous owners. At present a large, purpose-built extension is being built to one side, it was reported that this will provide a further 40 beds, more than doubling the capacity of the home. The manager reported that following this, the older part of the building would be up-graded and refurbished. Many of the bedrooms are large and some are well presented; however many others could do with attention. Although the home has four bathrooms, two on each floor, only two Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 22 of them are currently in use, as two of the bathrooms are too small to be used for residents with complex needs. One of the ground floor bathrooms has been improved since the previous inspection, with the provision of a disabled shower. The manager reported that bathing facilities will be addressed when the building is up-graded. Many residents expressed their appreciation of the facilities, one reported “I love the building”, another “It’s a nice room and my chair is comfortable” and another “We have a lovely view.” At the previous inspection it was required that all residents who needed nursing care were to be provided with height adjustable beds. The manager reported that four such beds had been delivered since the previous inspection, however this is not enough and it was noted that several people who had complex manual handling needs and people who needed to be fed by another person had not been provided with such beds. This is a risk to both residents and staff and the home needs to provide the CSCI with a clear written action plan as to when appropriate equipment will be provided to all people who need it. The home has a range of hoists and manual handling equipment available to support residents with manual handling needs. The home does have some air mattresses for people at risk of pressure damage, but as noted in standard 7 above, not all people at high risk of pressure damage had been provided with such a mattress or even a lower specification mattress. The manager reported that there was only one air cushion in the home. As risk of pressure damage does not reduce when sitting out of bed, these are indicated unless otherwise directed. Three of the air mattresses had settings on them which did not relate to the resident’s weight. Settings on air mattresses need to reflect the resident’s weight, if they are not set correctly, this can increase the person’s risk of pressure damage. Despite building work taking place close to the home, no builders’ dust was observed. Of the ten people who responded to this part of the questionnaire, five reported that the home was always, four usually and one sometimes clean. Comments varied through “Very clean” to “I would like a general clean more often” to “I feel the quality of the home is average as far as my standard of cleaning goes”. Discussions with one of the cleaners indicated that they had a good supply of cleaning chemicals and had recently been supplied with a new carpet shampooer. Many of the home’s commode chairs are old and need replacement, there was rust visible on some of the metal surrounds and some showed perishing plastic upholstery. The manager reported that these commode chairs will not be transferred to the new home. At the start of the first site visit, one commode bucket was observed to have been used by the resident. It had still not been emptied by 3:30pm. Nearly all of the commode buckets in residents’ rooms showed staining, odour and brown and black debris. Some of the commode buckets in the downstairs sluice room were clean but others were not, also Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 23 showing staining. The home only has one washer disinfector, on the ground floor, which may explain why some commode buckets had not been properly cleaned. The WC brush used for cleaning commode buckets in the first floor sluice room was placed in unclean liquid with debris in it. The outer sides of the container showed numerous drips of dried-on yellow matter. WC brushes need to be clean and dry, otherwise commode buckets will be recontaminated. There are two assisted WCs next to the dining room. One had a raised seat under which the WC was not clean. The other one had a grab rail. Dried-on yellow drips were visible on the underside of the grab rail. By the second site visit by the nurse inspector, these matters had all been addressed. However on the second site visit by our nurse inspector, one of the assisted WCs had a slipper bad pan in it with some yellow odorous liquid in the base and one room showed a commode bucket which had not been fully cleaned. It is appreciated that matters had largely been dealt with by the second site visit by our nurse inspector, however it should not take an inspection for appropriate action to be taken. High standards of cleanliness are needed when managing commode buckets and toilet aids to prevent risk of cross infection. There is one communal assisted bathroom on the first floor at the time of the first site visit, the back of the hoist showed large amounts of green staining. This should have been noted when the staining developed and the bath taken out of use until the hoist was fully cleaned. Use of an aid in such a state in a communal bathroom will present a major risk to cross infection and this should have been noted by staff and action taken prior to the inspection. It had been cleaned by the second site visit by our nurse inspector. One person who had records indicating that they experienced incontinence had a damaged and torn plastic cover on their mattress. This means that the foam mattress underneath could become contaminated and would present a risk to the next user of the bed. On the second site visit by our nurse inspector, one person’s room showed a slight odour. Protection had been provided to the metal frame of their bed. This protection was stained and odorous. The laundry was visited during the morning, a busy time of day. It was clean and well organised. There was no dust behind machines or elsewhere in the room. The laundress showed a good understanding of the principals of prevention of spread of infection, although she reported that she had not been trained in the area. She reported that she had a good supply of gloves and aprons when handling residents’ clothing. At present the home does not have a system for separation of laundry, other than separation of infected and potentially infected items. The laundress reported that staff consistently use red bags for such items. All other laundry is placed in the same receptacle and has to be re-sorted by the laundress, prior to washing. This is not regarded as good practice as it can present a risk to cross-infection. The manager reported at the third site visit that she had ordered appropriate bags to ensure that laundry could be separated. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 24 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 poor. This judgement has been made using available evidence, including visits to this service. Residents are not protected by the home’s systems for assessing staff for employment or assessments for the numbers of staff required to support residents’ nursing and care needs. Some supports are given to training but more emphasis is needed, to ensure that residents can be fully supported. EVIDENCE: The Cedars has a core of staff who have worked there for many years. The manager reported on how supportive and flexible her staff were and that they were prepared to cover for absences. This meant that the home had not needed to use agency staff for over 18 months. The manager reported in her annual quality assurance on the low levels of sickness amongst staff, this was supported by a review of records. As well as nursing and care staff, ancillary staff, activities coordinators, administrator and a maintenance man are employed. The Cedars has agreed staffing levels which specifies the minimum number of staff to be on duty every shift. It is to be noted that they generally keep to this minimum level of staff but do not go above it, despite admitting people for terminal care, caring for people with complex medical needs or people with acute dementia care needs. Staffing numbers need to be flexible, so as to ensure that the needs of the people in the home can be met. Of the Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 25 nine people who responded to this section of the questionnaire, four reported that there were always, three usually and two sometimes staff available when they needed them. Most people felt that staff responded promptly when they used their call bell, one person commented “They are active when I ring my bell” another “If you ring your bell they come and help you”, however a few people were not so confident, one reported “Staff are sometimes slow at coming” and another “They do their best”. Issues relating to staff performance were noted in standards 7, 8, 15 & 26 and these issues may relate to lack of availability of staff, rather than poor performance itself. The home needs to review of its staffing levels to ensure that the needs of residents in the home can be met. The files of four recently employed staff were reviewed. All four had police checks and included proof of identity. The pin numbers of registered nurses had been checked. The application form does not require that the person puts down their most recent employer or even the status of the referee, therefore it cannot be assessed if the most suitable person has been approached for a reference. One member of staff who had been in post for five months had only one reference on file and this was not from their most recent employer. This person had cited their previous, not current employer but there was no evidence that this had been probed prior to appointment. One person had a “to whom it may concern” reference dated two years previously. References must be directly sourced and be in date for them to provide correct information about the person. One person did not have an application form or CV on file, so there was no information on their previous employment or whether they were suitable for their role. Another person had not provided dates for previous employment on their application form and there was no evidence that this had been probed at interview. One person from abroad did not have copies of evidence on their file that they were able to work in this country. One of the four persons had an interview assessment tool completed but it did not provide evidence that all relevant matters in their application had been reviewed. Photographs of staff are retained on file, however as many of the photographs were photocopied of passport photographs, the image was not of a sufficient quality to fully provide proof of identity. The poor standards of systems for recruitment of staff has the potential to put vulnerable residents at risk as the home have not assured themselves that prospective staff members are fit for their role. All newly employed staff are given a standard induction, using a staged approach over their first six weeks of employment. Topics covered include all areas specified in guidelines, such as manual handling and safeguarding adults. All of the forms had been signed and dated by the inductor but not all areas had been signed by the inductee. This is needed to ensure that the home can verify that the inductee feels that they have understood each area covered. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 26 All staff have their own individual training record. These are not up-to-date. Some indicated, for example that several staff had not received manual handling training since 2005. However when this was cross referenced to certificates, it appeared that most of the staff had been trained in the area. The manager reported that she considered that all staff had been trained but the records might not all be up-to-date. There is a need for training records to be fully up-dated, so that training can be evidenced. The annual quality assurance record showed that the home does not yet have 50 staff trained to NVQ2 or equivalent. The manager reported that the home does support NVQ training. The manager also reported that they were organising training in areas relating to elderly care such as Parkinsons disease and dementia and that training would then be cascaded to staff. Training is not provided in all common conditions for elderly people, such as diabetes, prevention of pressure damage, bowel care, nutritional care or systems for promotion of continence. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 27 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, & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to this service. The home is managed by an experienced manager, but lack of quality audit, staff supervision and consistency in ensuring that principals of health and safety are applied means that some areas of risk to people are not properly identified and action is not always taken to reduce risk. EVIDENCE: The Cedars is managed by an experienced registered nurse, who has worked in this field for many years and who is also experienced in commissioning new buildings. Many of the residents spoken with expressed their appreciation of the manger, one reported “The matron’s very nice” and another “We see the Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 28 manager here”. The manager is supported by a night manager who also works days to support the manager and act as her deputy. The proprietor of the home, Alphacare Holdings Ltd has recently been purchased by another company. This company have been introducing their policies, procedures and systems, including their procedures for assessing quality. The home’s quality assurance folder appeared to be comprehensive. However, none of the sections had been completed to date, so it is not clear if any quality audits of service delivery have taken place since the previous inspection. This is needed so that the new owners can assess that the home are meeting residents’ needs. If assessments had been taking place, there may not have been unmet requirements from the previous inspection and some of the matters noted at this inspection may have been identified and action taken. Monthly management visits take place and a report is completed into the findings. References are made to the building and residents are seen in this report. No references were made to the previous inspection’s outstanding requirements or plans for action to be taken. The reports also did not identify areas found in this inspection relating to staff training documentation, staff supervision, staff recruitment, practice in health and safety, particularly prevention of spread of infection and accident records or deficits in assessments and care planning. Such matters should be reviewed during monthly visits, so that we can be assured that the owners of the home are identifying areas relating to Regulation and National Minimum Standards and taking appropriate action. The Cedars uses standard systems for management of residents’ moneys, with each individual resident having their own allocated computerised account. When residents wish for a particular service, such as hairdressing or chiropody, the home pays the supplier of the service and debits the resident’s individual account. Full receipts are maintained. Relatives are contacted when funds are becoming low and full accounts provided when requested. The parent company audits accounts regularly on an unannounced basis. There is limited evidence of supervision for staff. Some records show that the manager has provided some supervision to the registered nurses. There are no supervision records relating to care assistants. The manager reported that care assistants are supervised as she and her registered nurses work alongside them but that they have not maintained records relating to this. The manager reported that she had only reviewed supervision once from her line manager and that this was at her own request. Staff at all levels need to be supervised, so that they can receive the support they need, strengths and deficits in performance identified and training needs identified. The home has clear maintenance records. The fire log book was fully up-todate. Three members of staff spoken with commented on the regularity of the Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 29 fire training. At the first site visit, one resident was prescribed oxygen via a concentrator and had oxygen cylinders in their room. No British Standard fire safety warning signage was placed on the door of their room. This had been addressed by the second site visit by our pharmacist inspector. Where issues were identified during routine maintenance, action is taken. For example a report on the lift earlier in the year indicated that work was needed to ensure its proper functioning, the moneys for this work were reported to have been agreed and that the work would be progressed shortly. Staff reported that they were regularly trained in manual handling and had relevant aids to enable to them to perform safe manual handling. Domestic and laundry staff all reported that they had been trained in COSSH. All cleaning chemicals were securely stored. The annual quality assurance report indicated that 100 staff had been trained in infection control. However practice indicated that more emphasis needs to be placed on training to prevent spread of infection – see standard 26 below. The home maintains an accident book, and this was examined during the second site visit by our nurse inspector. Some of the records reviewed were not clear and did not identify the side of the body or digit affected, although in others such matters were documented. One record was written in such a way that it was not possible for an external person to assess what had taken place, the resident’s daily record did not further clarify the situation, although a subsequent record did document that the resident was experiencing pain. Accident records need to be clear and include all relevant information as they may be needed to be reviewed by external statutory bodies at a future date. It was reported that accident records are completed by the person in charge of the shift, not the person who first observed the occurrence. Statutory bodies advise that such records must be completed by the person who observed the occurrence, not a third party. It was noted during the inspection that several residents had been provided with safety rails. A brief assessment of need is completed. The home are advised to review advice from the Medicines and Health Care Regulatory Authority (MRHA) and Health and Safety Executive on the risks of using such rails, as the current assessment does not reflect all the areas that the MRHA and Health and Safety Executive have advised be considered. Individual care plans relating to the use of safety rails are not regularly evaluated, which they should be, to prevent risk of accident to residents. One person’s care plan documented that safety rail protectors were to be used. However when they were visited, the resident only had one bumper on, the other rail was not protected. This did not reflect what was documented and had the potential to put the resident at risk if one of their limbs came in contact for a period with the hard metal rail. One resident whose daily records indicated that they had a tendency towards restless behaviours, had references made to the use of safety rails and then their discontinuation in their daily records. When the person was visited, the rails remained on their bed. No care plan relating to the use of bed rails had been drawn up, so it was not clear if they were to be Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 30 used or if their use was in the best interest of the resident. Inconsistent systems for use of safety rails has the potential to put residents at risk of accident. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 31 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x 2 x x x 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 1 x 2 Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation Requirement Timescale for action 31/01/08 2. OP7 3. OP7 14(1,a)(2, The home must ensure that all b) service users have full assessments of their needs drawn up, including assessment for risk of pressure damage, falls and inability to use the call bell system. 13(4,c) Where a service user is assessed as having a need, a care plan must always be put in place to direct staff on how risk is to be reduced and care needs met. 15(2,b,c) Assessments and care plans must be reviewed monthly or when a service user’s condition changes. UNMET REQUIREMENT: Parts of this requirement were identified at the previous inspection of 5/7/06, with a compliance date of 15/8/06. Some progress has been made but a wide range of areas continue to need to be addressed. Where a service user has or is known to have a nursing or care need, a full care plan must DS0000015897.V345290.R01.S.doc 31/01/08 31/12/07 4. OP7 15(1) 31/12/07 Cedars Nursing Home (The) Version 5.2 Page 33 5. OP7 17(1,a)S3 (3,k) 6. OP8 13(1,b) 7. OP9 13(2) 8. OP9 13(2) 9. OP9 13(2) 10. OP15 12(1,a) 11. OP22 16(2,c) 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. Where a service user is unable to or needs support in moving themselves or taking in an adequate diet or fluids, a monitoring record must be put in place, so that staff can ensure that the needs of these frail people are being met. Where a service user’s GP or an external healthcare professional makes directives, there must be written evidence that these directives have been carried out, or if they have not been carried out, the reason why this is. The registered person must ensure that the safety of staff and service users is not compromised by the use of inappropriate blood testing devices. Recent information from the MHRA (Medicines and Healthcare Regulatory Agency) must be actioned. All medicines and dosages (including oxygen) must be listed on the medication administration record. Risk assessments for self administration must cover the method of management of the medicines by the individual service user and be regularly reviewed. Where a service user needs support to eat, this must always take place and in a prompt manner. The divan beds currently in use for service users with nursing needs must be replaced with an appropriate bed suitable to DS0000015897.V345290.R01.S.doc 31/12/07 31/12/07 31/01/08 30/11/07 30/11/07 30/11/07 30/11/07 Cedars Nursing Home (The) Version 5.2 Page 34 meeting the care needs of the service users. UNMET REQUIREMENT from the previous inspection of 5/7/06 with a compliance date of 15/9/07. 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. All equipment must be correctly used, in accordance with manufacturers’ instructions. 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 to cross infection. 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. No staff must be employed until all checks relating to their suitability have taken place and full evidence retained on their file. This must include past working history, two suitable references and evidence that they are able to work. Managers of the home must implement their own system for review of quality of service. There must be evidence that all DS0000015897.V345290.R01.S.doc 12. OP22 13(4,c) 30/11/07 13. OP26 13(3) 30/11/07 14. OP27 18(1)(a) 31/01/08 15. OP29 19(5,b,d) S2 30/11/07 16. 17. OP33 OP36 24(1,a,b) 18(2)(a) 31/01/08 31/01/08 Page 35 Cedars Nursing Home (The) Version 5.2 18. OP38 13(7) 19. 20. OP38 OP38 17(1,a)S3 (j) 13(3) 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 30/11/07 used, assessment of need and care plans must always be drawn up. These must be regularly evaluated. Care plans relating to the use of protection to safety rails must always be complied with. There must be clear records of 30/11/07 the circumstances of any accident to a service user. All staff must be trained in their 31/01/08 individual responsibilities for prevention of spread of infection. 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 The home should revise its statement of purpose, to fully reflect the types of people admitted and how they can meet their needs, including details of staff number and skill mix available on each shift. Care plans relating to wound care should direct staff on how often a wound’s progress to treatment is to be assessed. Where a service user’s fluid intake is monitored by use of a fluid chart, the amount of fluids taken in every 24 hours should be totalled. Medicines which have a shortened expiry date after opening should be dated when first opened. When assisting residents to eat, there should be enough staff available to ensure that opportunities to make the mealtime a pleasant, social occasion can be maximised. Improved systems for delivering meals promptly and in a DS0000015897.V345290.R01.S.doc Version 5.2 Page 36 2. 3. 4. 5. 6. OP7 OP7 OP9 OP15 OP15 Cedars Nursing Home (The) 7. 8. 9. 10. 11. 12. 13. OP16 OP29 OP29 OP30 OP30 OP33 OP38 14. OP38 safe manner to service users should be considered. A record of all informal concerns raised with staff and actions taken should be maintained. Photographs of staff in employment records should be clear, so that they can provide a proof of identity. The interview assessment tool should be used for all prospective staff and show that any discrepancies in application have been considered at that time. Training records should be reviewed an fully up-dated to provide full evidence of training participated in by staff. There should be evidence that staff have been trained in the range of medical conditions commonly experienced by older people. Monthly visits by a manager should consider progress in requirements and recommendations identified during the inspection process. A copy of the Medicines and Healthcare Regulatory Authority and Health and Safety Executive’s directives on the use of safety rails should be obtained and considered when developing documentation relating to safety rail assessments. Accident records should be completed by the person who first observed the accident, not a third party. Cedars Nursing Home (The) DS0000015897.V345290.R01.S.doc Version 5.2 Page 37 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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