Inspection on 06/10/05 for The Cedars Nursing Home

This inspection was carried out on 6th October 2005.

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

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

Other inspections for this house

The Cedars Nursing Home 04/02/09

The Cedars Nursing Home 25/02/08

The Cedars Nursing Home 01/02/07

The Cedars Nursing Home 18/07/05

The Cedars Nursing Home 03/05/05

The Cedars Nursing Home 03/02/05

The Cedars Nursing Home 30/09/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Cedars Nursing Home The Cedars Cedar Rd. Balby Doncaster South Yorkshire DN4 9HU Lead Inspector Sarah Powell Unannounced Inspection 6th October 2005 08:55 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Cedars Nursing Home Address The Cedars Cedar Rd. Balby Doncaster South Yorkshire DN4 9HU 01302 310668 01302 310852 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) Four Seasons Health Care (England) Limited (wholly owned subsidiary of Four Seasons Health Care Ltd) Post Vacant (Pending) Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66) of places The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named client under the age of 65 years will be allowed to remain in the home. This condition will cease to apply when the client leaves the home. 15th September 2005 Date of last inspection Brief Description of the Service: The Cedars is a care home located in Balby, Doncaster it is set in a residential area with shops and amenities nearby. It is comprised of two units. The units accommodate up to 66 service users over the age of 65. One unit accommodates service users that require nursing care and the other service users requiring personal care. Both units are on two floors accessed by stairs and a passenger lift. There is one kitchen and laundry for both units. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes third inspection in the year 2005/2006 the home has also had two additional visits between the inspections to check on compliance with the requirements and an immediate notice and investigate a complaint. This inspection took place over one day the inspection commenced at 08.55 and finished at 15.30. 18 Service users, 8 staff and 4 representatives were spoken to. A partial tour of the building took place, observing staff and practices; time was also spent in the office looking at policies, procedures, staff files, training records and other paper work. What the service does well: What has improved since the last inspection? The care plans continue to improve with staff gradually working through updating and reviewing to ensure all service users needs are identified and met. Risk assessments are also much improved. One staff member is now responsible for all training and is arranging training on care plans to ensure there is consistency and that they continue to improve. Training has greatly improved since the introduction of the training officer. The home now has an activities co-ordinator which has made a great improvement activities, outings and outside entertainment is now available to the service users. The response from service users regarding this was all very positive. Contracts have been issued to all service users and are gradually being returned. All staff have received training on adult protection and have been made aware of the necessity to report allegations of abuse immediately. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 6 Bathrooms are being improved throughout the home with new suites and redecoration. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 5 Information was available for perspective service users to make an informed choice and trial visits were available. EVIDENCE: The Statement of purpose and service users guide were looked at by the inspector both contained all the required information and had only just been updated by the management team. The home has now received the service users contracts from head office and they have been sent out to the relatives and are gradually being discussed with individuals, signed and returned. The manager is aware of the need to use advocacy services if required. Perspective service users are able to have trial visits to the home prior to making a decision. This is usually for one day staying for lunch and tea if requested, service users are also able to stay overnight if they would like. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 9 If the service user chooses to live at the home the first six weeks is a trial period and reviewed at the end of this period. The service user can then choose to extent the trial period or set up a permanent contract. This trial period also gives staff the opportunity to determine if they are able to meet the needs of the service user. Two fairly new service users were spoken to and they both stated that visits to the home prior to admission were offered. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,9, 10 & 11. Health care needs of the service users are met, maintaining privacy and dignity. EVIDENCE: Service users health care needs are met this is now documented in the plans of care that have been reviewed service users spoken to also confirmed that there health needs were met they were referred to specialists if required and had access to all health care services including chiropodists, dentists, opticians and district nurses to meet the needs of the service users. Staff spoken to were aware of the need to maintain privacy and dignity practices observed confirmed this and service users spoken to all said “staff respect me and maintain my privacy and dignity”. The home has policies and procedures in place for safe administration of medication. The home was currently changing its systems for disposal of The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 11 medication following the changes in legislation for care home providing nursing care. The manager has been given conflicting information is and currently trying to resolve this. The systems and changes were discussed during the inspection and it was evident the manager was ascertaining the correct procedure to implement in order that he complied with the changes with the legislation. The home uses cassettes for medication dispensed by the pharmacist and each individual medication administration sheet is kept with the cassette to prevent errors, these were signed correctly. Administration of medication was observed this was carried out correctly with the registered nurse following the homes procedures to ensure that the service users are safeguarded and their needs are met. Service users wishes regarding death and dying are documented in their plans of care. Staff spoken to were aware of the need to give care and comfort and maintain privacy and dignity. The home had recently had a number of deaths and they had received cards form relatives thanking the staff for their care not only to their relative who had died but also the support shown to the family. Two such letters were seen by the inspector and showed the home met the needs of the service users who were dying. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14 Service users have opportunity to exercise their choice in relation to leisure and social activities, maintain contact with family and friends. EVIDENCE: The activities within the home have greatly improved in the last two months. The home now has employed an activities co-ordinator who is doing an excellent job. The feedback from the service users regarding the activities was very positive they all stated it was a great improvement and they thoroughly enjoyed the activities organised. The activities co-ordinator was also doing some 1 to 1 activities for the service users who couldn’t or didn’t want to join group activities this was ensuring all service users needs were met. The activities were documented daily. There was also activity programmes displayed on the notice boards. Contact with family and friend is encouraged and all visitors spoken to all stated they were always made welcome and could visit at any time the choice was theirs and the service users. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 13 Service users are able to control their own lives as much as they are able this is documented in the plans of care with risk assessments. Service users told the inspector they were able to make their own choices and control their lives and were encouraged by staff to do this in order that their needs are met. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 Service users are protected from abuse and have clear complaints procedures to follow. Their legal rights are also protected. EVIDENCE: The home has a comprehensive complaints procedure, which states timescales to be followed and contact details of manager, head office and CSCI. The home has received three complaints since April two have been resolved and one is ongoing all complaints have followed the procedure. Relatives and service users spoken to were aware of the complaints procedure. Service users legal rights are protected they are able to participate in the civic process if they so wish, there is also access to advocacy services for service users who lack capacity to ensure the needs of service users are met. The home has a good adult protection policy, which has not always been followed in past incidences however, there was an incident alleged on the day of the inspection and the manager followed the procedure notifying all the relevant people and instigating the process. This has since been resolved with one of the staff involved being referred to POVA. The manager kept CSCI informed throughout the process and continually followed the protocol. Staff spoken to by the inspector had all received training on adult protection and were aware of abuse and the different types and the importance of notification if an incident is seen, in order to safeguard the service users. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 15 At the inspection in July an immediate requirement was issued as staff were working in the home with out a POVA clearance, all staff must have a POVA check prior to employment and can then only work under supervision until a satisfactory CRB has been obtained. The home had been employing the staff under supervision having sent for the checks but without either check obtained. This practice has now ceased and all POVA checks are obtained prior to employment to protect the service users. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21, 22, 23, 24, & 25. The environment in general meets the needs of the service users. EVIDENCE: The home provides adequate communal space for the service users the dining carpet on the residential unit is badly marked and stained however this is due to be replaced to improve the environment for the service users. Service users have sufficient toilets and bathrooms in the home. Some bathrooms are currently being upgraded installing new suites and redecoration; this needs to continue to include all bathrooms as the remaining ones are in a poor state of repair. Service users rooms observed on the day of the inspection were well decorated and maintained and met the needs of the service users. Some bedroom doors were propped open at the request of the service user these doors need to be fitted with self-closers. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 17 Specialist equipment was seen during the inspection for the service users to maximise their independence. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The home has a good skill mix of staff. EVIDENCE: The home has a good mix of staff with different skills however, staffing numbers and skill mix on duty were not always adequate to meet the needs of service users due to sickness. The duty rota showed that staffing met the minimum requirements however regularly staff called in sick at the last minute at weekends particularly, which leaves the shift short, the home is trying various incentives to reduce the sickness levels but so far none are appearing to work. The manager is to continue to look at this problem to try to resolve it in order service users needs are always met. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 37 & 38. The home is run in the best interests of the service users maintaining health and safety. EVIDENCE: The manager in post is still going through the registration process with CSCI; he is a registered nurse with many years experience. Staff spoken to all stated the home was gradually improving creating an open, positive and inclusive atmosphere, which then benefits the service users. Effective Quality assurance and quality monitoring systems are in place in the home. There are regular quality questionnaire sent out a recent one seen by the inspector was on meals and the returned questionnaires contained very positive comments. The results of the feedback are summarised and made The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 20 available to the service users and negative comments followed up to ensure the home is run in the best interests of the service users. The manager and senior management carry out regular quality checks and audits and regulation 26 visits are carried out the results of these are sent to CSCI. The homes administrator looks are money for some service users who are unable to maintain their own money. These records were seen written records of all transaction were maintained all receipts kept and the money was kept in a bank account, which is available at any reasonable time for the service users to access. Regular audits are carried out on service users money however, some cheques are being sent late from head office so service users are still needing their money so they are borrowing from the home until cheques arrive this needs to be looked at to ensure cheques arrive on time. All records seen were maintained up to date and accurate to safeguard the service users. The home has a good health and safety policy and safe working practices are followed to protect service users. All maintenance and service records were seen and up to date. On the tour of the building some bedroom doors were propped open this is a risk if a fire occurs so the door must be fitted with selfclosers to safeguard the service user in the event of a fire. The manager was unable to locate risk assessments for the safe working practice topics this needs to be found and a copy kept available to all staff to safeguard staff and service users. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 21 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 3 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X 3 2 3 3 3 3 X STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 2 X 3 2 The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement To continue reviewing plans of care to ensure all the plans of care are reviewed and include all relevant information to meet the health and welfare needs of the service users (old timescale 1.7.05) Ensure adequate staff with appropriate skills are on duty to meet service users needs. (Old timescale 1.7.05) Ensure that all the bathrooms are upgraded. Ensure risk assessment on safe working topics are carried out and made available to all staff. Provide self-closers on bedroom doors where service users wish them to remain open. Timescale for action 01/01/06 2. OP27 18 01/12/05 3. 4. OP21 OP38 23 12 01/04/06 01/01/06 5. OP38 12 01/04/06 The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 23 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. 2. Refer to Standard OP28 OP35 Good Practice Recommendations 50 of care staff are trained to NVQ level 2 by 2005. Resolve the issue of the cheques arriving late to ensure service users receive their money on time. The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Cedars Nursing Home DS0000015852.V260433.R01.S.doc Version 5.0 Page 25 - 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!