Inspection on 01/10/07 for Cedar House

This inspection was carried out on 1st 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.

Other inspections for this house

Cedar House 27/04/09

Cedar House 27/10/08

Cedar House 26/02/07

Cedar House 07/09/06

Cedar House 19/04/06

Cedar House 04/01/06

Cedar House 02/08/05

Cedar House 09/09/04

Cedar House 26/04/04

Cedar House 17/03/04

Cedar House 19/01/04

Cedar House 18/09/03

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cedar House 39 High Street Harefield Middlesex UB9 6EB Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 10:40 1 & 2 October 2007 st nd 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 House DS0000010927.V348430.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 House DS0000010927.V348430.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedar House Address 39 High Street Harefield Middlesex UB9 6EB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of Manager Designate (if applicable) Type of registration No. of places registered (if applicable) 01895 820 700 01895 820 600 www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Manager post vacant Care Home 42 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0) Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To comply with the Minimum Staffing Notice required by the previous regulator as at 31st March 2002. Five of the beds currently registered can be used for service users of 55 years of age and over, as agreed by the Commission for Social Care Inspection, on 1st February 2005. 26th February 2007 Date of last inspection Brief Description of the Service: The home is situated in Harefield village. The village centre is within walking distance of the home and public transport, that being bus services, are available. Cedar House offers care to service users who are over 65 and suffer from Dementia. It is a purpose built care home with service user areas on two floors and services and staff areas on the third floor. The floors are interconnected by a lift, which also accesses the third floor. There is parking to the front and an enclosed garden to the rear. The home is entered and exited by a keypad system. The administrators office is sited near the reception area. There is a designated person who oversees leisure activities. There is one GP who visits the home weekly. The fees range from £620 - £813 per week. Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 11 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 10 residents, 8 staff, 1 healthcare professional and 5 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from service users, representatives/visitors and health & social care professionals have also been used to inform this report. What the service does well: What has improved since the last inspection? Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 6 Equipment to be used for each individual to meet their moving & handling needs is now identified in the service user plan. Correct lancing devices for blood glucose monitoring are now in use and entries on the medication administration record (MAR) were legible. An environmental audit has been carried out and redecoration and refurbishment needs identified. There was evidence of some redecoration and refurbishment having been carried out. The passenger lift had been reviewed for security purposes and clear notices regarding the use of the lift are on display. 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 House DS0000010927.V348430.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 House DS0000010927.V348430.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): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a pre-admission assessment document that is completed for all prospective residents to ascertain if the home is able to meet the residents’ needs. In addition, copies of the Social Services needs led assessments are also obtained, to give the home further information about each resident. Cedar House DS0000010927.V348430.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): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were being completed to provide staff with the information to meet each resident’s needs. Shortfalls should be easy to address. Medications are being well managed at the home, thus safeguarding residents. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. Information regarding end of life care needs updating to ensure the current wishes of residents and their families are known and can be respected. EVIDENCE: Service user plans were sampled on each floor. Overall these were comprehensive and provided a clear picture of each residents’ needs and how these are to be met. New care plans had been formulated for newly identified needs. The care plan information reflected the residents mental health needs also. There was evidence of monthly review and updates of the service user plan documentation. Some reviews had taken place with the resident and/or their representative and these had been clearly documented. The need to ensure that all residents and, where appropriate, representatives are offered Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 10 the opportunity to be involved with service user plan reviews was discussed. In one service user plan viewed a risk assessment for falls had not been completed even though the resident had experienced a fall. The fall had been clearly documented in the daily record. For another resident a risk assessment and consent for the use of bedrails had been completed, although it was not clear that it was appropriate for bedrails to be used for this resident. The importance of ensuring all risk assessments and associated documentation is up to date, accurate, and reflects the current status of the resident was discussed. One resident had pressure sores and the documentation for these was viewed. Care plans had been formulated for each wound and wound progress records had been recorded, plus a photographic record kept, thus providing clear information regarding the progress of each wound. Pressure sore risk assessments had been completed for all residents. Nutritional assessments, moving & handling assessments and continence assessments had been carried out and care plans formulated to address identified needs. Where moving & handling equipment was being used, this had been identified on the assessment. The Inspector spoke with the homes GP who was satisfied with the care provided to the residents. The Manager Designate said that the home also has input from the psychiatric consultant and psychologist who visit every 6-8 weeks in conjunction with the GP to review any changes in residents’ mental health. There was evidence of input from other healthcare professionals to include a dentist who the Manager Designate reported is very experienced with caring for people with dementia and other mental health care needs, the optician, chiropodist, physiotherapist, community psychiatric nurse and tissue viability nurse, all of whom provide care relevant to each residents needs. The medication management and records were sampled for each floor. Medications were being securely stored at the home. Information to include each residents name, photograph, any known allergies and any special administration instructions was available for each resident. Where a resident is non-compliant with medications this has been fully discussed with the GP and residents representative and documentation signed regarding an appropriate system of administration to be used for each individual. Liquid medications had been dated when opened. Receipt and administration records were up to date and complete. Correct systems are in place for the disposal of medications. Some of the medication stocks were checked and found to be correct. The home has in place a single use lancet system for monitoring blood glucose levels, which is one of the systems approved for use in a care home setting. Fridge and room temperatures were being recorded and were within recognised safe ranges. There is an air conditioning unit in the clinical room and this was functioning well. The registered nurse reported that there were no residents receiving controlled drug medication, however appropriate secure storage facilities are available should this be prescribed for anyone. There was evidence that medications are reviewed regularly to ensure that residents only Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 11 receive medications essential to their wellbeing, and this was confirmed by the GP. Medications are being well managed at the home. Staff were seen caring for residents in a gentle and professional manner, with good interaction observed between staff and residents, thus respecting their privacy and dignity. Individual clothing is labelled and residents were well dressed, reflecting individuality. Some of the bedrooms viewed had been personalised and overall there was a very homely atmosphere. There were no cultural and diversity issues identified at the time of inspection. The Manager Designate said that he did have some information regarding the Mental Capacity Act 2005, which came into force on 1st October 2007, and the Inspector strongly recommended that training be undertaken in order to ensure the Manager Designate is up to date with current legislation. In the service user plans viewed care plans had been completed for end of life care needs and wishes. Some of the information was old and the need to ensure all information regarding the end of life care for each resident is current and reflecting of the wishes of the resident and their families was discussed. Changes in respect of the Mental Capacity Act 2005 and how this differs from previous legislation were discussed with the Manager Designate, and the Inspector advised that the home obtain information regarding this Act and the impact for the future on the residents and the home. Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home has improved, providing a variety of activities, outings and entertainments to meet the residents needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: The home has 3 part-time activities co-ordinators, all of whom have been employed in the last 2 months. Each has undertaken some training relevant to their roles, with further training being planned. The staff had started gathering information regarding the interests and hobbies of each resident. A ‘map of life’ document is being completed for each resident, providing information about their life history. A weekly activities programme is displayed in the home. There is a budget of £120 per month for activities, plus the home have fundraising events to provide more money towards activities and improving areas of the home in relation to activities. Examples of this are plans to convert an area of the activities room into a ‘virtual garden’ for residents, plus plans to Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 13 provide a sensory garden area in the enclosed garden. Some comment had been received regarding the lack of use of the garden, and the activities coordinators said that this is an area to be improved upon in the future. The senior activities co-ordinator also discussed the importance of ensuring that any healthcare needs that may impact on people’s ability to join in activities are identified and addressed, for example, provision and maintenance of hearing aids. Other activities in place include a pianist twice a month and Pat a Dog twice a week, which the residents get enjoyment from. A diary is being kept to evidence the activities each resident joins in. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and refreshments are offered. Visitors commented about the ‘homely’ atmosphere throughout. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms. Information regarding advocacy services was displayed in the reception area. The Manager Designate said that representatives from The Alzheimer’s Society and from Age Concern had attended relatives meetings and should a resident require an advocate then this would be arranged. One Inspector viewed the kitchen. This was clean and tidy and all the records were up to date. Residents are offered a choice of meals and documentation to evidence this was available. The menu is designed to provide options for those residents who can use cutlery and also for those for whom, due to their cognitive impairment, find it easier to manage ‘finger food’. Drinks and snacks are available throughout the 24 hour period. The lunchtime meal was observed and staff were available to assist residents with their meals where required. Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a robust system in place for the safeguarding of residents from abuse. EVIDENCE: The home has a clear complaints procedure, copies of which are on display and available in the Statement of Purpose and Service User Guide. There had been no complaints received since the last inspection. Documentation viewed showed that any complaints are recorded and responded to. Relatives spoken with said that any issues raised are taken seriously and the Manager Designate takes action to address them. The importance of ensuring that any concerns are identified to the Manager Designate so that he can address them was discussed with some visitors. The home has Adult Protection procedures in place and also follows the Hillingdon Safeguarding Adults procedures. During discussion one incident was identified to the Inspector and this was discussed with the Manager Designate and the Safeguarding Adults Officer for Hillingdon. The incident had been appropriately reported and action taken to address it. It had not constituted an adult protection matter. Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 15 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, 21 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home is being well maintained, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: The Inspector carried out a tour of the home. There was evidence of work having been carried out with redecoration and refurbishment, to include replacement of some carpets, more profiling beds in place, redecoration of some rooms and door furniture in place plus baskets of dolls and soft toys in the corridors in line with current dementia research. The home has an overall programme for redecoration and refurbishment and the Manager Designate said that the new budget starts from October each year and more work is planned and ongoing. The home has an enclosed garden that is secure for residents to go out into. Comment was received that it would be nice for residents to go out into the garden more, and the senior activities co-ordinator Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 16 said that he is aware of this and action can be taken to address this in the good weather. Work had been carried out to remove the sticky substance found on the bathroom windows at the last inspection. There are bathing, shower and toileting facilities available to meet the needs of the residents and all bedrooms have en suite facilities to include a toilet and a wash hand basin. The laundry room was clean and tidy. The washing machines have a sluice programme for infection control purposes. The home was clean and fresh throughout. Protective clothing to include gloves and aprons was available in the home. Policies and procedures for infection control are in place, plus good practice notices in line with infection control were seen in the laundry and kitchen areas. Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being appropriately staffed to ensure that the needs of the service users can be met. Systems for vetting and recruitment practices are in place to safeguard residents. There is an ongoing training programme, providing staff with the skills to meet the needs of residents, to include specialist care needs. EVIDENCE: At the time of inspection the home was being staffed to meet the needs of the residents. The Manager Designate said that he does ensure that where additional needs are identified then the staffing is reviewed accordingly. On the second day of inspection someone rang in sick and action was taken to replace them as soon as was possible. Some comment was received from representatives regarding the staffing of the home at various times and interaction between staff, and these points were fed back to the Manager Designate. 3 activities co-ordinators have been employed since the last inspection. The home has also employed a full-time administrator and this has been a positive move, ensuring that the administration areas of the home are now being managed effectively, and not impinging on the Manager Designates duties. Kitchen, domestic and maintenance staff are employed in such numbers as to meet the needs of the residents and the home overall. The home has accessed NVQ in care training with several staff now registered to undertake level 2. 7 staff are qualified to NVQ 2 or above in care and 4 Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 18 senior care staff are qualified as nurses in their own countries. 5 more care staff are starting NVQ level 2 in care training. Southern Cross Healthcare are corporately aware of the need for 50 of all care staff to be qualified to NVQ level 2 or above, and this needs to be progressed. The Manager Designate said that he has accessed and arranged the NVQ in care training for his staff, as well as other training sessions. Southern Cross Healthcare do have a Training Co-ordinator that should also be involved in ensuring training is facilitated for all staff. Three sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001. The home has an induction programme that meets the Skills for Care common induction standards. Staff had indicated in the staff surveys that they had been well inducted on commencing work at the home. One induction booklet viewed did not include all the common induction standards, although the sections that had been completed were comprehensive. The Registered Manager said that he would follow this up. The training matrix viewed indicated that some staff had received periodic training in topics relevant to the needs of the residents, to include dementia care training. Further training sessions had been arranged for staff. Health & safety training is commented on under Standard 38. Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager Designate has the qualifications and experience to manage the home, and does so in an open and approachable manner. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are good, however some poor practice could place residents at risk. EVIDENCE: The Manager Designate is a first level registered nurse with a mental handicap qualification. He has been in post for 18 months, and previously worked for several years as a unit manager in a care home environment. He reported that he has now completed the Manager Designates Award, NVQ in management Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 20 level 4. The Manager Designate said that he has submitted his application for registration as the Manager Designate to CSCI, however this is still in the process of submission due to additional information required. Following the inspection the Manager Designate has attended the CSCI Regional Registration Team office in order provide information to forward his application. Staff and representatives spoken with said that the Manager Designate is approachable and supportive, and deals with any issues raised. The home has a system of audit in place and there was evidence of monthly home audits to include many aspects of practice within the home. Staff meetings take place, with the minutes taken. The Manager Designate has a weekly evening for meeting with visitors, plus he operates an ‘open door’ policy so service users, staff and visitors can discuss any issues with him. Visitors meetings take place and visitors are encouraged to give their views about the home. Regulation 26 unannounced visits to the home on behalf of the Responsible Individual are carried out. The Southern Cross Healthcare policies and procedures were last updated in January 2006. The home has updated the system it has for managing any personal monies held on behalf of residents. The records for this were viewed for 3 residents and entries for income and expenditure were clearly recorded. Group invoices from the chiropody and hairdressing visits were seen and the administrator provides individual receipts for each resident for all income and expenditure. All records for the management of personal monies on behalf of residents were clear and up to date. The maintenance and servicing records were sampled and those viewed were up to date and clearly recorded. There was evidence of regular fire drills taking place for day and night staff and the weekly alarm system check was carried out on the second day of inspection. Risk assessments for equipment and safe working practices were in place. Good practice notices were seen in the laundry and the kitchen. The Manager Designate had identified the need to have in-house moving & handling trainers and 3 staff had undergone this training. All staff are to receive moving & handling training and updates during October 2007. On the first day of inspection the Inspector observed poor moving & handling practice and update training for the person concerned has since been arranged. Training in food and nutrition has also been planned. The training matrix did not evidence that all staff had undergone fire safety training and training in other health & safety topics in the past 12 months, however the administrator explained that there were still some training sessions that had taken place to be entered onto the matrix. Since the last inspection the security for the passenger lift had been reviewed and notices to explain clearly how to use the lift were on display. Overall health & safety is being well managed at the home, however all staff must follow correct procedures to ensure the safety of the residents. Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 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 X 3 X X X X 3 STAFFING Standard No Score 27 3 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 2 Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(3) Requirement Risk assessments to include falls risk and use of bedrails must be complete, accurate and up to date, and be appropriate to the safety of each individual resident. Information regarding the wishes of residents in the event of deterioration in their health, plus their care in their final days must be ascertained and recorded, so that their needs and wishes can be respected. There must be evidence that all new staff complete a full induction and foundation programme. Correct moving & handling techniques must be used at all times when handling residents to protect them from the risk of harm. There must be evidence that all staff have undertaken training and updates in health & safety topics at the required intervals, thus providing them with the necessary knowledge and skills to care for residents safely. DS0000010927.V348430.R01.S.doc Timescale for action 19/10/07 2. OP11 12 01/11/07 3. OP30 18 01/12/07 4. OP38 13(5) 01/10/07 5. OP38 18 01/11/07 Cedar House Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP10 Good Practice Recommendations The Manager Designate and home staff should be familiar with the Mental Capacity Act 2005 and the implications of this in relation to the ongoing management of the home and meeting the needs of the residents. Southern Cross Healthcare should ensure they provide appropriate resources for NVQ in care and other training needs, so that training can be provided in a timely manner. 2. OP28 Cedar House DS0000010927.V348430.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 House DS0000010927.V348430.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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