Care Home: The Cedars Nursing Home

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What the care home does well The meals provided were nutritious, wholesome and appealing, the cook was very knowledgeable on the needs of the people and how to meet them. She also had a good understanding of people who required enriched and fortified diets and had excellent measures in place to ensure these were provided. People’s needs were assessed prior to moving into the cedars to determine they could be met. A well maintained homely environment is provided and the standard of cleanliness was very good throughout the home. There was a comprehensive health and safety policy. Regular maintenance of equipment and systems was carried out ensuring peoples safety. What has improved since the last inspection? Care plans had been rewritten identifying peoples needs and measures in place to meet those needs. Risk had been identified and risk management measures documented in plans of care. Care plans were reviewed regularly or when changes occurred and problems identified were followed through with an outcome documented ensuring peoples needs were met. Medication procedures protected people good records were in place, which were clear and detailed. It is therefore possible to determine that people received their medicines correctly. Staff had received most training appropriate to the needs of the people which ensured people’s needs could be met. No further safeguarding referrals had been received and people were protected by the homes polices, procedures.The Cedars Nursing HomeDS0000015852.V376507.R01.S.docVersion 5.2Qualified nursing staff had been recruited and there were adequate number of nurses employed to ensure people’s needs were met. A deputy had also been recruited to support the management of the home. The acting manager had applied to the commission to become the registered manager and her interview was scheduled for 29 July 2009. Quality monitoring had recommenced and two quality monitoring questionnaires had been sent out on in April and one in June 2009, we looked at the returned questionnaires and comments were very positive. What the care home could do better: Some training was still required to ensure staff were appropriately trained to meet people’s needs; this included specific training in illnesses associated with old age, including dementia training. Independent advocates should be used when required to ensure decisions are made in peoples best interests. More activities need to be provided to meet all people’s needs, the acting manager had recruited two new activity co-ordinators but was awaiting Criminal Record Bureau (CRB) checks before they could start. The environment on the residential unit could be improved with redecoration in a number of rooms and communal areas. Key inspection report CARE HOMES FOR OLDER PEOPLE The Cedars Nursing Home Cedar Road Balby Doncaster South Yorkshire DN4 9HU Lead Inspector Sarah Powell Key Unannounced Inspection 14th July 2009 09:20 DS0000015852.V376507.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars Nursing Home Address Cedar Road Balby Doncaster South Yorkshire DN4 9HU 01302 310668 01302 310852 cedars@sshc.co.uk www.fshc.co.uk Four Seasons Health Care (England) Limited (wholly owned subsidiary of Four Seasons Health Care Ltd) Sharon Teresa Clark Care Home 66 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) Category(ies) of Old age, not falling within any other category registration, with number (66) of places The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. For the home to be able to admit up to three service users aged 60 65 within the category of registration 1st February 2007 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 people over the age of 65. One unit accommodates people that require nursing care and the other unit accommodates people 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. Fees range from Residential Care £ 375:00 per week, Nursing Care £553:00, at the time of the visit additional charges are made for hairdressing, chiropody, optical, dental services and magazines. For further information contact the home. Information about the service is available to service users and their families via the home’s Statement of Purpose and the Service User Guide. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been revised or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. This was an unannounced visit, which took place on the 14th July 2009. The visit commenced at 09:20 and ended at 15:30 hours. Two random visits had taken place since the last inspection to check compliance with medication requirements, these visits were carried out by a pharmacy inspector. These took place on March 2009; we found non compliance with the requirements and following this we issued two statutory requirements notices. A further visit took place on 29th April 2009 to determine if the notices had been complied with. We found that the requirements made under Regulation 12(1) (b) set out in the statutory requirement notice issued on 31st March 2009 had been met. We found no evidence that medicines to be administered to people living in the home were unavailable at the time of need. We also found that the requirements made under Regulation 13(2) set out in the statutory requirement notice issued on 31st March 2009 had been met. Information has been used from different sources for this report. These sources includeNotifications (Regulation 37) relating to incidents in the home affecting people using the service. Details of complaints and allegations raised by people connected to the service. Reviewing information that has been received about the home since the last inspection. This inspection visit included talking with people living at the home, their relatives, a number of professionals, the acting manager, deputy manager and eight staff. During the visit we also walked round the building to gain an overview of the facilities. We also checked a number of records. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 6 The acting manager had not received a request to complete an annual quality assurance assessment (AQAA) at the time of the visit. The acting manager has downloaded one and completed it prior to the report being sent out in draft. The AQAA focuses on how well outcomes are being met for the people using the service. It also gives us some numerical information about the service Full feedback was given during and at the end of the inspection to the acting manager. What the service does well: The meals provided were nutritious, wholesome and appealing, the cook was very knowledgeable on the needs of the people and how to meet them. She also had a good understanding of people who required enriched and fortified diets and had excellent measures in place to ensure these were provided. People’s needs were assessed prior to moving into the cedars to determine they could be met. A well maintained homely environment is provided and the standard of cleanliness was very good throughout the home. There was a comprehensive health and safety policy. Regular maintenance of equipment and systems was carried out ensuring peoples safety. What has improved since the last inspection? Care plans had been rewritten identifying peoples needs and measures in place to meet those needs. Risk had been identified and risk management measures documented in plans of care. Care plans were reviewed regularly or when changes occurred and problems identified were followed through with an outcome documented ensuring peoples needs were met. Medication procedures protected people good records were in place, which were clear and detailed. It is therefore possible to determine that people received their medicines correctly. Staff had received most training appropriate to the needs of the people which ensured people’s needs could be met. No further safeguarding referrals had been received and people were protected by the homes polices, procedures. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 7 Qualified nursing staff had been recruited and there were adequate number of nurses employed to ensure people’s needs were met. A deputy had also been recruited to support the management of the home. The acting manager had applied to the commission to become the registered manager and her interview was scheduled for 29 July 2009. Quality monitoring had recommenced and two quality monitoring questionnaires had been sent out on in April and one in June 2009, we looked at the returned questionnaires and comments were very positive. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 8 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.V376507.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 does not apply. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All people in the home had their needs assessed prior to moving into the home to ensure these could be met. EVIDENCE: The acting manager told us all people’s assessments had been reviewed and rewritten on new assessment documentation introduced by Four Seasons. The The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 10 assessments we looked at were very thorough and clearly identified the person’s needs in order to determine if these could be met at The Cedars. We looked at assessments for new residents these were fully completed and clearly identified their needs. Assessments from placing authorities were also available in the plans of care. This enabled staff to understand people’s needs and be able to meet them. A new person was due to arrive on the residential unit the afternoon of the visit, the senior carer showed us the documentation that was ready for them prior to admission, it was well organised and showed the persons needs had already been assessed to determine The Cedars could meet those needs, prior to admission. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person in the home had a plan of care with clearly identified needs, these were met, and people were treated with respect. Medication procedures protected people. EVIDENCE: Two plans of care were looked at in detail. The care plans had been rewritten since the last key inspection and were very good. The plans had identified the needs of the people with good recordings of the measures to take to meet their The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 12 needs. The plans were regularly reviewed; people and their relatives were involved in this process. This ensured their views were listened to and their needs met. The acting manager had also started to include evidence that the mental capacity act had been taken into consideration, with regard to peoples capacity and choices this ensured peoples needs were identified and met allowing them to make choices and decisions regarding their care. One person who at lived at the cedars for a long period of time, had no family involvement and no allocated social worker. The staff were making decisions for them, where they lacked capacity; involvement of an independent advocate would be in the best interests of the person to ensure decisions were made appropriately. All health care needs were met and regular input from health care professionals was obtained. Their advice was followed and well documented in the plans ensuring the wellbeing of the people who lived in the home. People were treated with respect and privacy and dignity upheld. During the visit we observed interaction between staff and residents, the interactions were positive and the people told us staff are very good, we are looked after very well. One relative told us, “Things have really improved and it seems a different home”. At the compliance visit on 29 April 2009 we found on examination of the current month’s medication administration record (MAR) charts that there were no significant gaps in the records. The quantities of medicines brought forward from the previous month were accurately recorded on the new charts, the actual quantities given of variable dose medicines e.g. warfarin, were clearly recorded and new charts for carers to record the use of skin preparations were in place. The labels of medicines with a limited life once opened were annotated with the date of first opening. A new bound controlled drugs register had been purchased and no discrepancies were found in the controlled drugs records. The GP prescription forms were checked each month by staff ordering the medicines before the medicines were supplied by the community pharmacy to ensure any changes or omissions are dealt with appropriately. The acting manager told us that all nurses working in the home had received a training update on the safe handling and recording of medicines and that communications between nurses about medication discrepancies had improved greatly. This is borne out by the findings of audits conducted by the local FSHC Regional Manager and also by a pharmacist from the supplying community pharmacy. During this visit we looked at medications for the two people whose plans of care we looked at in detail. Medications were appropriately recorded and all The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 13 skin preparation records were signed for by care staff when this was applied. The records we saw on this visit showed the staff were maintaining the standards reached at the compliance visit ensuring peoples needs were met. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most people exercised choice and control over their daily lives and activities ensuring their needs were met. Good contact with family and friends was maintained and an appealing balanced diet was provided. EVIDENCE: At the time of the visit no activity co-ordinator was employed as the previous person had left. The acting manger had successfully recruited two new coordinators; she was waiting for the necessary checks to be completed before they could start in post. The start date for both co-ordinators was 27/7/09. The care staff were providing activities for people on the nursing unit. On the residential unit staff told us they were very busy with one person, so The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 15 sometimes it was very difficult to provide activities for the residents. Therefore people’s social and recreational needs were not always being met. Relatives and friends visit at any time and were always made welcome. Relatives said the staff are always polite and welcoming when they visit. One said, “I am always made welcome”. We observed staff offering people choices and respecting people’s decisions. People received a wholesome, appealing and nutritious diet. We observed a lunchtime meal. Tables were nicely presented with tablecloths, napkins and menus displayed on each table. The food was well presented and choices were available to ensure people’s needs were met. Liquefied food was presented in a manner, which was attractive and appealing. The meal was unhurried and assistance was given sensitively when required. We had at previous visits spoken to the cook who was extremely knowledgeable on people’s needs, in particular in relation to fortified and enriched diet. She had various methods of ensuring people received adequate nutrition. The head cook was not working on the day of the visit; however the cook on duty was also very knowledgeable on peoples needs. One relative told us “The food is very good”. A person told us, “There is always a choice and if you want something else you ask the cook and she will do you what you want”. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who lived in the home were listened to and protected. EVIDENCE: There was a comprehensive complaints procedure, which was clearly displayed, in the entrance hall. All people we spoke to were aware of the procedure and told us they would either speak directly with the acting manager or staff. The manager had received one concern, this was raised as a result of a quality monitoring questionnaire sent to all residents and relatives. Good records were kept of the concern raised and outcomes. This showed they had been fully investigated, acted on, taken seriously and resolved. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 17 All staff had received training in adult safeguarding; all staff we spoke to had a good knowledge of the procedures and what to do should an incident occur. Staff were also aware of the whistle blowing policy, which safeguards people in the home. The manager also had a copy of the local authority safeguarding policy. This ensured the staff were aware of the local procedure. A number of safeguarding referral had been received prior to the last inspection these had been investigated and concluded, the local authority were waiting to case conference these, which is when relatives are invited to hear the outcomes and then the case is closed. No further referrals had been received since the last inspection. The provider had after the previous inspection voluntarily suspended admissions to the nursing unit. They had agreed this would remain in place until the new acting manager has resolved the issues and Doncaster safeguarding were confident practises have improved, to ensure people are protected from risk of harm. The suspension on admissions was lifted in June 2009, as Doncaster safeguarding had carried out a number of visits and were confident practices had improved. The acting manager told us practices would continue to improve to ensure this is sustained. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 18 The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well maintained clean, pleasant and comfortable ensuring people lived in a safe environment. EVIDENCE: The environment continued to be maintained to a high standard. A maintenance and renewal programme was in place most bedrooms, bathrooms, toilets and communal areas were well decorated and maintained to The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 20 a high standard. The lounge on the nursing unit had been redecorated and new furniture provided this looked very homely and comfortable. The grounds were tidy, safe and attractive and accessible to people. However more seating could be provided outside for people to use in the summer. The acting manager had identified some areas on the residential unit that required redecoration, some bedrooms, and communal areas and some bedroom carpets required replacing. This was included in the maintenance and renewal programme. This ensured people lived in a well maintained home. The standard of cleanliness observed throughout the home was to a high standard. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff skill mix met the needs of people on the nursing unit but not always on the residential unit due to peoples changing needs. Not all staff training was up to date. The recruitment procedures were robust ensuring people were in safe hands at all times and were protected. EVIDENCE: The staff on duty met people’s needs and the skill mix was appropriate to the assessed needs of people. However one person’s needs had increased on the residential unit and staff told us, at times they were struggling to meet everyone’s needs with the number of staff on duty. Following discussions with the acting manager at the end of the visit, she told us she would provide more staff, the person had been reassessed and there was already 5.5 hours a day one to one for the person, an additional carer would also be provided for the afternoon shift this would ensure enough staff The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 22 were on duty during the day to provide one to one care for the person whose needs had increased, this would meet peoples needs. The acting manager said she would review this weekly with the unit manager on the residential unit to ensure people’s needs were met. Not all mandatory training was up to date, the staff training matrix the manager was referring to was not up to date, it did not always correspond to what we found in staff files. The acting manager told us she would go through all files to determine what was required and ensure all training staff required was delivered. We identified some training during our visit that staff required this included first aid, safeguarding and dementia. Since the visit the manager has confirmed in writing dates for courses that have been arranged, first aid is arranged for 31 July 2009, safeguarding is arranged for 3 & 5 August 2009 and dementia training is being organised by Doncaster Councils Home Care Liaison team and dates were not yet confirmed. All staff completed induction training, new starters had either started or were due to start, although they had completed a basic induction from the acting manager. NVQ training was ongoing although 75 of care staff had achieved NVQ level 2, this ensured people were in safe hands at all times. The acting manager is also looking at providing more courses specifically relating to conditions that affect the elderly, this will enable staff to be aware of different conditions and how to manage them and meet people’s needs A thorough recruitment procedure was in place, we looked at two staff files, the procedure had been followed and all the required information and appropriate checks had been obtained. This ensured people were Protected. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 23 The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration safeguards people, good health and safety policies and procedures were in place ensuring the safety of people in the home. EVIDENCE: The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 25 The acting manager had been in post since 1 January 2009, she had previously been a registered manage. She is an experienced manager and had previously managed another home in Doncaster owned by the same provider as the cedars. The acting manager has completed the registered managers award and has submitted an application to the Care Quality Commission to become the registered manager. The interview is on 29 July 2009. Quality monitoring was carried out; the manager did regular audits and had regularly sent quality-monitoring questionnaires to people in the home and their relatives. This ensured the home was run in the best interests of the people who lived there. We looked at the results of the quality monitoring questionnaires returned in July 2009 the comments received were very positive and reflected the improvements made over the last few months. The home managed some people’s finances and personal money. We checked two records with the administrator, which were correct. The acting manager told us all records were maintained and all receipts were kept, ensuring peoples financial interests were safeguarded. A recent audit had also been carried out by Doncaster council’s contracts officers, this showed good procedures were in place and no errors identified at the time of the visit. The home had a comprehensive health and safety policy. We were able to evidence that regular maintenance of equipment and systems was carried out. Risk assessments were carried out on all safe-working practices, regular audits were carried out on the building and all accidents were properly recorded and reported ensuring people in the home were safeguarded. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 26 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 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 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 27 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 OP12 Regulation 16 Requirement People’s social and recreational needs must be identified and met. This requirement has been carried over 2. OP30 18 All mandatory staff training must be updated to ensure staff are able to meet the needs of the people. Including first aid training. This requirement is revised 3 OP27 18 Appropriate numbers of staff must be on duty at all times on the residential unit to ensure people’s needs are met. 01/08/09 01/09/09 Timescale for action 01/09/09 The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 28 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 OP19 OP8 Good Practice Recommendations To continue to redecorate and improve areas identified within the maintenance and renewal programme. To access independent advocates when required. The Cedars Nursing Home DS0000015852.V376507.R01.S.doc Version 5.2 Page 29 Care Quality Commission Care Quality Commission Yorkshire & Humberside Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshireandhumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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