Inspection on 30/11/05 for Two Cedars

This inspection was carried out on 30th November 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

Two Cedars 23/06/09

Two Cedars 27/06/07

Two Cedars 22/01/07

Two Cedars 25/08/05

Two Cedars 28/02/05

Two Cedars 28/07/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Two Cedars 81 Dunyeats Road Broadstone Poole Dorset BH18 8AF Lead Inspector Chris Gould Unannounced Inspection 30th November 2005 09:55 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 Two Cedars DS0000004066.V269475.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. Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Two Cedars Address 81 Dunyeats Road Broadstone Poole Dorset BH18 8AF 01202 694942 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) Mr John Williams Mrs Jean Lillian Williams Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th August 2005 Brief Description of the Service: Two Cedars is registered as a care home with the Commission for Social Care Inspection and may accommodate up to 17 older people. It is privately owned and managed by Mrs Williams. Two Cedars was built in 1908 and more recently had an extension built which incorporated further bedrooms and sitting area. The extension is in keeping with the style of the original building. It is close to the village of Broadstone, which has shops, a post office, banks and buses into Poole, Wimborne and Bournemouth. The care home is set well back from the road, in large, mature, well kept gardens which are easily accessible to service users. There is a large patio area accessible through French doors from the lounge. There is ample car parking space. The three-storey house provides accommodation for service users on the ground and first floor. The second floor provides office and private accommodation. There are 17 single en-suite rooms, with adequate communal bathing and toilet facilities strategically placed around the house. The lounge and dining room are spacious. Three rooms on the first floor have access to a balcony overlooking the garden. A passenger lift is available between the ground and first floors. The service users have an emergency call system and staff are provided 24 hours a day. Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over two hours on one day in November 2005. The previous inspection had taken place in August 2005 and a pharmacy inspection in September 2005. This inspection assessed 10 standards and the outstanding requirements from the previous inspections. A tour of the premises took place and relevant documentation was viewed. Eleven residents and the staff on duty were spoken with. Jean Williams the owner and registered manager was on duty and assisted in the inspection process. This report should be read in conjunction with the inspection report dated 25 August 2005. What the service does well: All residents have individual plans of care to ensure their health, personal and social care needs are met. Social activities provide variation and interest for the residents living in the home. Residents spoken with agreed that they looked forward to the social activities provided especially the music and sing-a-longs. Residents had enjoyed a performance the previous day from the brass band of a local school. The standard of the environment is good providing the residents with a, safe, well maintained place to live with access to all areas of the home and garden. The training provided ensures that staff have the knowledge and skills to meet the needs of the residents safely. The residents live in a home that is well managed by Mrs Williams the proprietor. Discussions with staff show that they are clear about their roles and responsibilities within the home and feel that they are important members of the team. Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Two Cedars DS0000004066.V269475.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 Two Cedars DS0000004066.V269475.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): EVIDENCE: Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 All residents have individual plans of care to ensure their health, personal and social care needs are met. The home’s medicine policy needs updating so that it is relevant to the home and sufficiently detailed to instruct staff in the procedures to follow for the safe handling, safe administration and recording of medicines to protect residents. EVIDENCE: It was identified during the last inspection that although all residents have detailed assessments and action plans, a bed rails assessment had not been undertaken for one resident who required them. A bed rails assessment has now been developed and implemented. Following an inspection undertaken in September 2005 by the CSCI pharmacy inspector the requirement to ensure that medicines are given as prescribed and accurately recorded has been met. The medicines policy still needs to be reviewed and updated, as they are not current and referred to nurses, which is not appropriate in this home. Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 10 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 Social activities provide variation and interest for the residents living in the home EVIDENCE: Residents spoken with agreed that they looked forward to the social activities provided especially the music and sing-a-longs. Residents had enjoyed a performance the previous day from the brass band of a local school. There were two jig saw puzzles partly completed by residents and others said they played cards, read books, listened to music or watched the television. Mrs Williams had started to decorate the home in preparation for Christmas. Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 The standard of the environment is good providing the residents with a, safe, well-maintained place to live with access to all areas of the home and garden. EVIDENCE: The care home is a converted house that had been extended to provide additional bedrooms and lounge area. The premises are maintained to a good standard and there was evidence of a routine maintenance programme. A passenger lift provides access between the ground and first floors. The gardens are attractively laid out and a patio provides a seating area. An officer from the Dorset Fire and Rescue Service last visited the home in March 2004 and an Environmental Officer in December 2004. Recommendations resulting from the two visits have been met. Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 13 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): 28, 29 and 30. The training provided ensures that staff has the knowledge and skills to meet the needs of the residents safely. Appropriate checks have not been undertaken prior to the member of staff commencing employment so potentially leaving service users at risk. EVIDENCE: It was not possible to assess compliance with the requirement from the previous inspection to ensure Protection of Vulnerable Adults clearance is obtained before employment is commenced, as further recruitment has not taken place. Of the fourteen care assistants at the home four have achieved NVQ level 2 in care or equivalent and six are currently undertaking the training. The other four care workers are at present undertaking a colleague course in care. Care assistants spoken with confirmed that they were provided with and attended the training they needed to provide care for the residents. Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 14 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 and 36 The home is run by a person who is of good character and able to discharge her responsibilities fully ensuring residents live in a home that is well managed. To safeguard residents the programme that has been developed to ensure staff are appropriately supervised needs to be implemented EVIDENCE: Mrs Williams the proprietor and registered manager of the home has an NVQ level 4 in Management and a nursing qualification so does not need to achieve NVQ level 4 in care. Discussions with staff show that they are clear about their roles and responsibilities within the home and feel that they are important members of Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 15 the team. Staff agreed that they all get on very well together and work towards providing the best care possible for the residents. Mrs Williams has recently completed a course on supervising staff. Together with a senior care assistant who has also completed the staff supervision course Mrs Williams has developed a programme to be used for supervision of care staff working at the home but this still needs to be implemented. Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 X X Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 17 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 OP9 Regulation 13(2) Requirement The medicines policy should be reviewed and personalised for the home so that procedures are sufficiently detailed for staff to work to. Timescale of 14/11/05 not met. The registered person must obtain Criminal Records Bureau and Protection of Vulnerable Adults checks for all staff. Protection of Vulnerable Adults clearance must be obtained before employment is commenced. This requirement was not assessed during this inspection as no further recruitment had taken place therefore the timescale has been extended. The registered person shall ensure that persons working at the home are appropriately supervised. Timescale of 30/11/05 not met. Timescale for action 31/03/06 2 OP29 19(1) 31/03/06 3 OP36 18(2) 31/03/06 Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 18 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 OP9 Good Practice Recommendations The home should have a Controlled Drugs cupboard for storing CDs and a CD record book for recording receipt, administration and disposal or return of CDs (see information enclosed). Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Two Cedars DS0000004066.V269475.R01.S.doc Version 5.0 Page 20 - 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!