Inspection on 22/05/08 for Cedar Grange

This inspection was carried out on 22nd May 2008.

CSCI found this care home to be providing an Good service.

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.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 28/10/2008.

CARE HOMES FOR OLDER PEOPLE Cedar Grange Crosslanes Landstephen Launceston Cornwall PL15 8JN Lead Inspector Mike Dennis Unannounced Inspection 22nd May 2008 09:00 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 Grange DS0000071538.V364247.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 Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedar Grange Address Crosslanes Landstephen Launceston Cornwall PL15 8JN 01566 773049 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) Cornwall Care Ltd Miss Geraldine Joan Maureen Hodge Care Home 60 Category(ies) of Dementia (60), Mental disorder, excluding registration, with number learning disability or dementia (60), Old age, of places not falling within any other category (60), Physical disability (60) Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) - maximum 60 places Physical disability (Code PD) - maximum 60 places Dementia (Code DE) - maximum 60 places Mental disorder, excluding learning disability or dementia (Code MD) maximum 60 places The maximum number of service users who can be accommodated is 60. None (New Home) 2. Date of last inspection Brief Description of the Service: Cedar Grange is a new purpose built home and provides care for 60 elderly people who need care for the reason of old age, dementia, mental disorder, and physical disability. The home also provides nursing care. The building is slit into four units or suites as they are known, each accommodating up to 15 residents. Each suite has a personalised name. Keypads on entrances aid security. Each suite has a kitchenette - which allows some simple food and drink preparation - dining area and sitting room and adequate bathing and toilet facilities. Main meals are prepared in the main kitchen, and are transported to each wing by a heated food trolley. Activities are arranged within the home and service users can also partake of activities and functions arranged by the day centre if they so choose. As stated, Cedar Grange is a new build home. It is modern, well designed and offers an array of facilities which are detailed in more depth under the ‘environment section of this report. The weekly fees at May 2008 were given as from £600 to £1000 Cedar Grange DS0000071538.V364247.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 the people who use this service experience good quality outcomes. This was a planned unannounced key inspection. The purpose of the inspection was to focus on the key national minimum standards as identified by the commission. We were on the premises for two full days. The methods used were discussion with the manager, staff, residents, and their relatives, inspection of records and documents, observation of the daily life of the home and inspection of the premises. A period of short observation framework inspection was undertaken within a lounge area of the home for a period of approximately 2 hours. This exercise is a recognised process developed for the CSCI in conjunction with Bradford University to enable Inspectors to sample outcomes for people who use services where direct communication is not always possible. We are grateful to the providers, staff and residents for their assistance in completing the inspection. Given that Cedar Grange is a brand new resource and that this was the first inspection, a very good start has been achieved. Documentation to include policies, procedures and required records are all up and running and being competently maintained. Relatives and residents expressed positive comments and stated they were happy with the care provided and delighted with the environment. Inevitably there have been teething problems but these have been rectified. The manager stated that there were some areas where improvement can be achieved, but overall a good start has been achieved. What the service does well: Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 6 Cedar Grange provides a safe and comfortable home for older people. Residents and their representatives stated that Cedar Grange provides good quality care and accommodation. Comments made by residents included ‘The home has a nice atmosphere’, ‘The staff do care well’ and ‘The staff are very kind’. Residents and their representatives felt that that their health needs were well monitored and appropriate referrals made promptly. The provider obtains assessment information from the appropriate authorities before admission and carries out its own needs assessment. Residents felt their visitors were welcomed to the home. Residents, relatives and staff felt that they could approach the manager with any concerns and issues. Residents were particularly satisfied with the quality of the meals provided. The home is well maintained, tidily decorated and kept clean and hygienic. The staff team has a number of staff who transferred from Miller House, the home that Cedar Grange has replaced and are therefore familiar with the needs of residents who also transferred and of course with general routines. This has helped with the settling in period and continuity of care. Residents made positive comments about the staff’s kindness, skills and attitudes. Staff stated that the informal and formal supervision supported them to do their jobs. Cornwall Care has a sound training programme for staff. The provider supports and encourages staff in their training and development so that residents and their representatives can have confidence in a well trained and supervised staff team. Staff were satisfied with the training they receive and with the support from the management team. What has improved since the last inspection? Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 7 This is the first inspection at this newly registered home. 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 summary of this inspection report can be made available in other formats on request. Cedar Grange DS0000071538.V364247.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 Cedar Grange DS0000071538.V364247.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5. People who use 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. Prospective residents receive the information they require in order to make an informed choice about residing at Cedar Grange and their needs are assessed so that they can be assured that the home can provide the care required. EVIDENCE: The Statement of Purpose and Service User Guide has been completed and is made available to all current and prospective residents. The service user guide should contain a full and explicit complaints policy. Contracts and/or statements of terms and conditions of the home are in place in respect of each resident. Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 10 Managers visit prospective residents and complete a needs assessment. Cornwall Care Ltd uses a standard format for assessment and care planning. When completed in sufficient detail, this record covers the assessment issues specified in the standard and the diverse needs of prospective residents. All the residents’ records case tracked contained needs assessments completed by the home’s managers. The records contained summaries of social work assessments, and joint assessments from local health agencies and Cornwall Department of Adult Social Care. The assessment records for recently admitted residents recorded their assessed needs in detail and included their views and preferences. The home’s assessments state who was present at the assessment. This provides evidence that the prospective resident and their family, or representatives, were involved in the assessment to ensure that their diverse needs were recorded. Relatives felt that the home involved them in the resident’s care arrangements. Residents and relatives informed us that they were given the opportunity to visit the home prior to moving in. Cedar Grange DS0000071538.V364247.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use 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. Residents health, personal and social care needs are set out in individual plans of care which are regularly reviewed and amended. Medication procedures are appropriately followed EVIDENCE: All the residents case tracked had written care plans. Cornwall Care Ltd has a standard single format for assessment and care planning. These care plans were dated and signed, with dated records of regular reviews. The records for residents include a written life story. The care profile summarises the interventions required from staff. The care profiles directed and informed care staff in detail in meeting the health, personal and social care needs of residents. Residents’ preferred social activities and interests are included in the written Occupational Profile and Plan. The Personal Routines and Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 12 Preferences records detail residents’ lifestyle preferences and choices, their dietary preferences and needs, and their religious beliefs. There were good examples of individual care planning. All residents case tracked had a moving and handling assessment. Cornwall Care use a standard format for this. These assessments had been reviewed regularly. Where a resident is at risk of falling, there was a separate and detailed risk assessment to direct staff in reducing the risk and safeguarding the resident. The examples of falls risk assessments inspected were completed in detail with clear strategies for managing the risks. The managers carry out regular audits of falls as part of a strategy to reduce the incidence of falls and support an appropriately active lifestyle. The daily records for residents detailed the care delivered, visitors, health care matters, occurrences and activities. Staff keep separate records in respect of bathing, and other specific individual care needs. The contents of the residents’ records met regulatory requirements. Residents are registered with local GP practices. Residents felt that their health care needs were monitored and attention obtained promptly when needed. Care staff record each resident’s medical contacts and appointments. There are also written plans where required for eye care, foot care and dental and oral care. Residents are weighed regularly. Medicines are stored in locked medicine trolleys and further secured within a locked medical room. An appropriate Controlled Drugs cabinet is available but not yet in use as no controlled drugs are present at the home. Medication storage areas were tidy and well organised. There is a small medicines refrigerator and the temperature is checked daily. The monitored dosage system is in use. Residents sign an agreement to the administration of medicines. Some residents may self administer their own medication from time to time and rooms have a lockable storage area. Cornwall Care has a corporate policy and procedure on the handling of medicines, which includes guidance on the use of homely remedies. Specific named staff, managers or care coordinators, complete training and have responsibility for the administration of medicines. The administration records were well maintained. Two staff check in stocks of medicines delivered from the pharmacist. Two staff must always check and sign hand written medication records, drawn up, for example, when residents are admitted for respite. A record of medicines returned to the pharmacist is kept on the pharmacy standard format. Residents made positive comments on the skills and caring qualities of staff. They felt very well cared for and reported that staff delivered care sensitively and respected their privacy and dignity. Residents made statements like, “wonderful” and “would not like to go anywhere else”. Residents felt safe when, for example, staff were transferring them and providing personal care in Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 13 the assisted baths. Examples of staff providing skilled and sensitive care were observed during the inspection. Cedar Grange DS0000071538.V364247.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14, 15 People who use 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. Residents are supported to follow a lifestyle, which accords as far as possible with their own choices and preferences. The diet provided is varied and nutritious with attention to individual preferences. EVIDENCE: Residents felt that they had control over their daily lives and routines. The home provides some regular planned activities including arts and crafts, hairdressing, and musical entertainment. Residents also have the opportunity to join in the day centre activities. Some staff have had hand and foot massage training. Staff support residents in their own preferred individual activities and interests. The visiting arrangements are flexible and residents choose where they meet their guests. Residents felt that their visitors were made welcome. Visitors Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 15 confirmed that the home’s visiting arrangements suited them and staff make them welcome. The Manager stated that she does not act as appointee for any residents for their benefits or manage any savings. A minority of residents manage their own finances. Other residents’ finances are managed with informal assistance from relatives or through Power of Attorney arrangements. Residents can bring in possessions and furniture by agreement with the provider. The Manager was very positive about the Cornwall Care ‘appetite for life’ initiative for residents to receive a varied and appealing diet in a relaxed atmosphere. Breakfast is served flexibly according to individual preferences. The choices include cereal, toast, fruit, juices, a cooked breakfast and drinks. Residents were very happy with the choice at breakfast. There are two main choices each day at lunch. Further choices are available to individual residents who would prefer something different. Tea is a choice of savouries and home made cakes. The cook discusses the menu choices with residents. Residents made positive comments about the quality of food provided. They can choose to have their meals in their room or in the dining area. There was a relaxed and unrushed atmosphere during lunch with staff providing appropriate and effective support. Residents enjoyed a glass of wine or a non-alcoholic drink with their choice of meal. Residents reported that the meals were very good with appetising choices and sufficient portions. Meals were well prepared and presented. Drinks are served between meals. Cedar Grange DS0000071538.V364247.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use 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 has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. There are arrangements to protect service users from abuse. EVIDENCE: Cornwall Care Ltd has a corporate complaints procedure. Cedar Grange has received no formal complaints since the home opened approximately six months ago. There is a record for complaints and compliments. Residents and representatives had confidence that they could approach the managers at the home with their concerns and these would be addressed. Cornwall Care Ltd has an adult protection policy and procedure. The policy and procedure compliments the local Multi-Agency Adult Protection Guidelines. Staff receive training in adult protection following their induction and as part of their NVQ level 2. All senior staff have had training in safeguarding vulnerable adults. The Manager stated that the majority of care staff had received the Cornwall multi-agency alerter’s training. Staff were aware of their responsibilities to report concerns about the protection of vulnerable adults. Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 17 The Manager has a copy of the Cornwall Multi-Agency Adult Protection Guidelines. Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 to 26 People who use 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 is generally well maintained and provides a safe environment. The premises are clean and hygienic providing a pleasant environment and reducing risks to residents. EVIDENCE: Cedar Grange is a new build, two storey home on a sloping site so that both the ground floor & lower ground floor have level access at the front or rear. Internally, floors are accessed by stairs or shaft lift. Accommodation comprises: Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 19 • • • • 60 beds divided into four units of 15. Central reception/coffee area (manned 9.0am – 5.0pm daily), therapy room, hairdressing & Domiciliary Care office in central area. Manager & clinical nurse leads’ offices also central. Front door has a video camera as a security check. All rooms have • Sizes in excess of national minimum standards • En suite wet floor rooms with showers • Under floor heating • Alarm facility that can be activated, according to risk assessment, to alert staff if service user moving about in room • Nurse call to staff pagers bell in main station • Good views, well finished. On each unit: • Communal area for sitting and dining – spacious, selection of chairs • Small kitchen in communal area where staff and service users, if able, can prepare breakfast, drinks, light meals and snacks. • Main meal delivered from central kitchen. • Assisted bathroom, assisted shower & additional WCs near communal part. • Sluice. Generally throughout home: • Additional seating areas with views or a features such as fish, holographic pictures and general art work. • Wide corridors with signage and hand rails • Door to stairs & exterior secured with keypads as needed but staff carry override device that allows them free access • Activity/meeting rooms • Doors to garden have optional alarms – as per bedrooms – to enable free access to service users • Nursing beds & additional equipment – hoists, wheel chairs & toilet aids available. Kitchen and laundry areas are modern and supplied with up to date equipment. Externally garden being developed with paved pathways, seating and nocturnal lighting. Sensory planting planned. Paved garden can be seen from most parts of the home. Building completion certificate seen Equipment commissioned Fire risk assessment completed Gas worthiness certificate seen Company insurance increased Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 20 Paths around the building that lead away from final exit fire doors had been laid and security fencing around perimeter erected. Noted that access to Domiciliary Care Agency office is via main door & through reception but does not intrude into living areas. The construction and layout of Cedar Grange has been carefully designed and the home presents well both to the eye and to it’s practicality for use by both staff and residents. Residents and relatives spoken with all commented favourably and the general opinion is that people are proud of their new home. Cedar Grange DS0000071538.V364247.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use 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. Recruitment procedures support and protect the service users. Staff are trained and competent to meet the needs of residents. The staffing levels are generally satisfactory. EVIDENCE: Residents commented that they felt staffing levels were sufficient. The manager stated that minimum staffing levels are intended to be at least one qualified nurse on duty 24hours per day, 10 care staff throughout the day and evening. At night there will be one nurse and 4 care workers. The management team comprises the Registered Manager, Deputy Manager, Lead Nurse and a Care Co-ordinator. Other staff employed include, Housekeeper and 4 domestics, laundry person, driver/handy person, kitchen staff, receptionist and admin support. Residents were positive about the skills, kindness and qualities of the staff team. Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 22 Over 90 staff have completed their NVQ in care at level 2. and other staff are currently undertaking the course. The Cornwall Care Ltd training structure ensures that all new staff are registered promptly for their NVQ training. Posts are advertised through the Job Centre and local press. Cornwall Care Ltd has standard corporate recruitment procedures including equal opportunities. The records of the most recently recruited members of staff showed that the required employment checks had been properly completed. Staff records for established staff contained the required documents and information. Staff receive a statement of terms and conditions of employment. Cornwall Care Ltd provides a structured corporate training programme for staff, which covers required areas of training. Training records showed that staff had completed training in moving and handling, dementia care, food hygiene and health and safety. Recently appointed staff had begun their inductions. Staff were satisfied with the training they receive to do their jobs. At present there is not a full compliment of nursing staff. A recruitment program is underway. Due to this reason, nursing patients have not yet been admitted to the home. Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 People who use 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 provider has appointed an experienced and qualified manager who maintains the care delivery to meet the homes stated purpose and objectives. The health and safety of residents and staff is promoted. EVIDENCE: The manager of Cedar Grange is Geraldine Hodge. She has managed several care homes. Geraldine has a Bsc(Hons) Health and Social Care Management, and is also qualified in Dementia Care Mapping (DCM) in conjunction with Bradford University. Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 24 She is supported by the deputy manager who has worked for Cornwall Care for over 6 years and holds an NVQ 3 in social care. The deputy is currently completing her NVQ 4 in Management. There are clear lines of accountability from the manager through the other senior staff, who each have specific areas of responsibility. Staff were positive about the support and supervision that they received from the manager. Residents felt that the Manager would listen to and address any concerns that they might have. Cornwall Care Ltd has corporate policies for the management of residents’ monies and the home provides safekeeping for small amounts of money. Each resident has a record detailing payments in and out, and a running balance, with receipts for all expenditures. Each resident’s balance is not held as an individual amount of cash as this would amount to a large sum for the home to hold. The money is held in a specific bank account with a float available for daily transactions. A separate cash book details all payments in and out of the cash float. The administrator has systems in place for checking and reconciling the amount of cash, the bank account balance, and the individual resident’s recorded balances. Cornwall Care Ltd has previously sought the views of residents and their representatives, and other stakeholders through questionnaires. The manager stated that an initial quality assurance survey has recently been carried out. The staff records showed that staff received supervision sessions, some as individual sessions and some as small group wing meetings. Each member of the senior staff team is responsible for supervising a number of staff. The frequency of supervision requires slight improvement. Staff were satisfied that informal and formal supervision supported them to do their jobs well. They stated that if they sought guidance and information, this was always provided. Staff felt that they worked well together to ensure the well being of residents. Cornwall Care Ltd has comprehensive policies for health and safety. The Annual Quality Assurance Assessment detailed required maintenance and safety records. A sample were checked against the original records and found to be accurate. Staff have attended relevant health and safety training. Staff reported that Cornwall Care Ltd promotes safe working and manages health and safety well. The accident record for both residents and staff was inspected. The records showed weekly tests of the fire alarm system and the emergency lighting and regular fire training for all staff. There is a written fire plan. The home’s fire risk assessment has been completed. Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 25 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 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 3 Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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. 1 Refer to Standard OP36 Good Practice Recommendations The regularity of staff supervision should be increased to ensure all staff receive documented supervision at least 6 times per year. Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cedar Grange DS0000071538.V364247.R01.S.doc Version 5.2 Page 28 - 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. 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