Latest Inspection
This is the latest available inspection report for this service, carried out on 19th October 2007. 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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
For extracts, read the latest CQC inspection for Cedar Falls Nursing Home.
What the care home does well Residents were well cared for by a well managed, educated, committed and competent care team. Those residents and visitors who were spoken to expressed satisfaction with the care and service provided by the home. All residents were assessed before entering the home and there was a recreational and activity programme, which provided stimulation. There was a thorough assessment and review of care with wherever possible resident and relative/family involvement. There was a comprehensive programme of education provided which ensured that staff knew how to care and support people living in the home. Residents lived in clean, very well decorated, comfortable, safe and attractive accommodation. What has improved since the last inspection? An extensive programme of redecoration and refurbishment including providing new curtains, bedding, furniture, carpets has taken place throughout the home. This has resulted in a very comfortable home and every resident and visitor we spoke with was very pleased with the result. New lighting had been installed with new chairs in the lounges and new dining room furniture. A new disabled accessible shower room had been provided on the first floor. Two new hoists together with new lifting equipment had been purchased to assist staff with moving residents safely. As a result of the last Environmental Health Officer`s inspection by South Holland District Council on the 20/1/2007 the home was awarded 3 tulips (excellent) award for its catering service. What the care home could do better: There were no requirements or recommendations from this inspection. Where improvements are required these have or are taking place. The home continues to meet and in some areas exceed the national minimum standards. CARE HOMES FOR OLDER PEOPLE
Cedar Falls Nursing Home Little London Road Spalding Lincs PE11 2UA Lead Inspector
Tobias Payne Unannounced Inspection 19th October 2007 08:15 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 Cedar Falls Nursing Home DS0000002636.V352814.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. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Cedar Falls Nursing Home Address Little London Road Spalding Lincs PE11 2UA 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) 01775 713233 01775 713220 nike.ajewole@twhealthcare.co.uk www.tanglewoodcarehomes.co.uk Tanglewood (Lincolnshire) Limited Manager going through the registration process at the time of the inspection Care Home 93 Category(ies) of Old age, not falling within any other category registration, with number (93), Physical disability (12) of places Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The Physical Disability (PD) Registration Category will apply only to the bungalows. Bungalows accommodating service users with a physical disability must be single occupancy. Bungalows accommodating service users with a physical disability must have environmental adaptations and equipment provided, according to individual assessed needs. 19th July 2006 Date of last inspection Brief Description of the Service: Cedar Falls Care Home is situated in the market town of Spalding, which provides wide range of amenities including shops, pubs etc. It is part of the Tanglewood Healthcare Group, which operates five care homes in Lincolnshire. The home comprises a two storey main building, with a lift to the first floor, and 12 bungalows situated in the grounds. The home is registered to provide nursing and personal care for 95 older people in the main building, and 24 in the bungalows, although the bungalows are single occupancy at present. On the day of this inspection visit there were 75 residents in the home. This included 65 in the main building and 10 in the bungalows in the grounds of the home. The bungalows were also registered to accommodate up to 12 people with physical disabilities All bedrooms are of single occupancy with the majority having en-suite facilities. The home is decorated and furnished to a high standard, and has 9 quiet sitting areas. The extensive gardens are laid to lawns and flower- beds, with outdoor seating provided. The fees at the inspection on the 19/10/2007 ranged from £336 to £416 each week. Extras are for hairdressing which range from £5 to £20, chiropody £14.50, toiletries, personal newspapers and magazines. The statement of purpose, service user’s guide and information about the home could be obtained from the reception and manager of the home. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection visit was unannounced and started at 8.15 am. It was undertaken using a review of all the information available us about Cedar Falls Care Home. We spoke with 12 residents, 8 staff, 4 visitors, one community nurse and the manager. Discussion also took place with the company’s Complaints and Regulation Manager who was visiting the home during part of the inspection visit. The main method of inspection was called “case tracking”. This involved selecting 2 residents and tracking the care they received through the checking of records, discussion with them, the care staff and observation of their care. We also examined an Annual Quality Assurance Assessment completed by the manager. What the service does well: What has improved since the last inspection? What they could do better:
There were no requirements or recommendations from this inspection. Where improvements are required these have or are taking place. The home continues to meet and in some areas exceed the national minimum standards.
Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 6 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. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 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 Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is clear information about the home. This enables residents to decide about whether or not they wish to come to the home. Residents receive an assessment, which results in their needs being met. EVIDENCE: There was a detailed statement of purpose and service user’s guide. These were in the process of being reviewed. Each resident received a welcome pack, which described in detail about the home. This also contained terms and condition of residence. All residents were assessed before entering the home and written confirmation was sent to them that the home was able to meet their needs. A resident commented, “they handled my respite care well and I have been made very welcome”. The home did not provide intermediate care. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and welfare needs are met by comprehensive care planning and staff know the needs of the residents. Medication is safely given by staff who know what they are doing. Residents are protected by clear medication procedures. EVIDENCE: All residents had care plans describing their needs. Records included an admission sheet, a care plan with the resident’s needs, aims of care support, possible approaches and outcomes. Each entry was dated with a signature. Care plans included where required risk assessments and specific details about night care. The care plan included assessment records relating to all daily living activities, social care, dietary assessment, body map, moving and handling and where applicable risk assessment and care plan outlining their needs with evidence of review. Wherever possible the home obtained the signature of the resident/relative to the care plan. There was sufficient information to give staff information about how to care and support the residents. Residents felt staff knew about their needs and were satisfied with the care and approach from staff.
Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 10 Staff were seen to have evident pride in their work and attended to people promptly and with little fuss. The last pharmacy visit was on the 28/3/2007. There were no concerns. A named nurse was responsible for medication and records were well maintained for receipt, administration and disposal. We observed a medication round. The medication was dispensed from a trolley, checked against the chart, given to the resident and signed for after this. Nurses and senior care assistants were responsible for the administration of medication. The manager using a protocol assessed each person as competent. There was no concern about the medication arrangements. Residents were satisfied with the way staff cared for them and had confidence in the staff. Comments were, “I can’t find fault”, “the staff do their best” and ”I always find the staff polite, respectful and courteous”. We spoke with a visiting Community Nurse who commented, “I find staff provide a professional service. They respond correctly and I have confidence in the staff”. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 11 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): Standards 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Social activities were varied and provide daily stimulation and interest for people living in the home. Visitors were made to feel welcome. Meals provided are nutritious and varied. EVIDENCE: Activities in the home were provided by an Activities Co-ordinator who worked in the home 38 hours a week. There was a written activities programme and newsletter. This information was displayed throughout the home on notice boards. Examples seen on the day were sing a longs, birthdays and church services. There was information about the dial a ride service as well as the complaints and adult abuse procedure. We also saw musical entertainment taking place in the ground floor lounge with 25 residents attending. There was a hairdressing salon in the home. We spoke with 4 visitors all of whom were satisfied with the home and care provided. Comments were, “I can visit when ever I wish”, “I have confidence in the staff” and “I always find the home clean and the staff friendly”. The last Environmental Health Officer’s inspection by South Holland District Council was on the 20/1/2007 and as a result the home was awarded 3 tulips
Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 12 (excellent) award for its catering service. There was a menu with choices. An alternative was available if a resident did not like what was on the menu. Lunch was observed in the 2 dining rooms, which were newly decorated with residents having lunch attended by care staff who wore plastic aprons and served food in a discreet and unhurried manner. Residents who needed assistance were helped in a sensitive and dignified manner. No resident had any complaints about the food and it was well served by catering staff. Comments from residents were, “the food is very good”, “my husband’s dietary needs have been taken into account and there is plenty of food provided with good portions”. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 13 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints received are treated properly and residents and visitors know that any complaints they have would be addressed and taken seriously. Staff are recruited correctly to ensure that residents are protected from abuse. EVIDENCE: There was a complaints procedure displayed at the entrance to the home and each person received a copy of the complaints procedure in the service user’s guide and this information was displayed in each bedroom. The home and the commission had received no complaints since the last inspection. We had been informed by the home of an adult protection issue in September 2007. The investigation by Lincolnshire County Council was not yet complete. The home had followed the correct procedures and we had no concerns about the care and welfare of the residents. No one had any complaints about the home during the inspection visit. Staff were correctly recruited with an application form, references obtained, and induction. Staff knew about abuse and their role and training had been provided for all staff on abuse prevention. The home had an up to date adult protection policy and a copy of the latest Lincolnshire’s adult protection procedure. Throughout the inspection we saw that staff were polite and respectful when talking to or undertaking care duties with residents. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 14 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): Standards 19, 20, 23 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in clean, well decorated, safe accommodation. Equipment is provided to ensure that residents are independent as much as possible. EVIDENCE: The home was clean, tidy, well decorated and odour free throughout. Since the last inspection there had been extensive redecoration and refurbishment of the home. In November 2007 a further 20 bedrooms would also be redecorated to a similar standard. There were attractive and comfortable lounge and sitting areas throughout the home. All the residents and visitors we spoke with spoke highly of the accommodation and how much they liked their bedrooms. There was a shaft lift installed. All equipment such as hoists, alternating pressure mattresses and baths/showers had been well maintained. There was a separate laundry with commercial washing machines and commercial tumble dryers as well as laundry equipment. Residents’ comments
Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 15 were, “the home is always clean and comfortable”, “my bedroom has been redecorated with a new carpet during this year” and “my clothes are looked after well”. The gardens were very attractive and well maintained. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 16 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): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is adequately staffed with people who are experienced and competent to meet the needs of the residents. Residents are protected by robust safe recruitment practices. The training provided enables the staff to have the skills and knowledge to give safe care and support. EVIDENCE: Staff, residents and visitors felt there were sufficient staff in the home. The manager monitored dependency and was able to employ more staff where required. Training provided since the last inspection had included food hygiene, health and safety, moving and handling, equality and diversity, fire prevention, abuse awareness, first aid, medication, male catheterisation and nutrition. There were also 22 care staff who had obtained qualifications in care (National Vocational Qualifications) level 2 and 4 care staff level 3. In addition, 2 catering staff had level 2 and one with level 3 and 2 housekeeping staff with level 1, 2 with level 2 and 2 in progress. There was a high level of training provided. Staff were correctly recruited. We checked 3 staff records. There were pre-employment checks, photographs, application forms, 2 written references, Criminal Records Bureau check, terms of employment and a supported 12 week induction programme.
Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 17 Staff commented, “I enjoy working here, we work well and have a good team”, “We are busy but we have time to care” and “we have a lot of training”. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 18 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): Standards 31, 32, 33, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The day to day needs of the home are met by an experienced competent manager and staff team. Residents are kept safe by well maintained, up to date health and safety policies. EVIDENCE: Since October 2007 the home had a new manager who was a registered nurse and had been a manager at another Tanglewood home. She had considerable nursing and managerial experience and had obtained a management qualification. She was to apply to us to be registered in the future. Staff and residents had confidence in the manager. Comments from residents and visitors were, “I have no concerns”, “I am very satisfied”, “I can’t find fault with anything” and “ I have seen recent improvements”. Staff received supervision regularly and spoke of the support received from the manager.
Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 19 Regular quality assurance surveys were carried out and a future survey was to be sent out in November 2007 to obtain the views of residents. There were monthly unannounced visits by a representative of the company and copies of the reports were seen. There were regular internal audits on nursing and catering. The home had policies and procedures including clinical procedures. There was a detailed equality and diversity policy, which referred to religion and culture and there was a spiritual bill of rights. The manager was aware of the Mental Capacity Act 2005 and had attended training about equality and diversity. There were no concerns about equality and diversity. Records examined on the day of the inspection were available, well maintained and up to date. Equipment was well maintained. The home had a comprehensive and detailed health and safety policy together with detailed risk assessments covering all aspects of daily living activities. A detailed fire risk assessment had also been carried out. There were regular tests of the fire system as well as regular fire drills. Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 20 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 3 3 Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 21 No Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cedar Falls Nursing Home DS0000002636.V352814.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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
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