Inspection on 19/04/06 for Cedar House

This inspection was carried out on 19th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cedar House 27/04/09

Cedar House 27/10/08

Cedar House 01/10/07

Cedar House 26/02/07

Cedar House 07/09/06

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 19th April 2006 10:00 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 House DS0000010927.V286667.R01.S.doc Version 5.1 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.V286667.R01.S.doc Version 5.1 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 registered manager (if applicable) Type of registration No. of places registered (if applicable) 01895 820 700 01895 820 600 Southern Cross Healthcare Services Limited 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.V286667.R01.S.doc Version 5.1 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. 4th January 2006 Date of last inspection Brief Description of the Service: The home is situated in Harefield village. The village centre is within walking distance from the home and public transport in the form of bus services, is available. It is a purpose built care home with single bedrooms throughout. The home has 3 floors, two of which accommodate service users and the third floor houses the kitchen, laundry and staff facilities. The floors are interconnected by a passenger lift. There is parking to the front and an enclosed garden to the rear of the building. There is a secure entry system in place. There are two General Practitioners providing input for the home, both of whom visit weekly. Monthly visits from a psychologist and a psychiatrist take place to review the service users mental health needs. Input is also received from other healthcare professionals. The new Manager Designate had been in post for 2 weeks. There is also a Deputy Manager for the home. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 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 13 hours was spent on the inspection process. The Inspector carried out a tour of the home, and a selection of service user plans, staff records, financial records and maintenance records were viewed. 6 service users, 7 staff and 6 visitors were spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia care needs. What the service does well: What has improved since the last inspection? Information about the home has been updated, and further updates are planned. The formulation and upkeep of service user plans has improved, and overall records are maintained up to date and give a clear picture of service users needs. Minor shortfalls identified should be easy to address. Medication management has improved in the home, although some shortfalls have been identified. Better attention to detail should make these easy to address. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 6 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. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 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.V286667.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 4. The home does not provide intermediate care. Service users and their representatives are provided with information about the home. Service users are assessed prior to admission to ensure the home can meet their needs. Staff have not received up to date training in mental health and dementia care, and are therefore not fully skilled to meet the specialist needs of the service users. EVIDENCE: The home has a Statement of Purpose and a Service User Guide, and these were updated following the last inspection. There has since been a change of manager and it was agreed that the documents would be updated to reflect this. A copy of the Statement of Purpose was made available in the reception area, and can be obtained on request. Copies of the Service User Guide are made available to the service users and/or their representatives, as appropriate. Pre-admission assessment documentation viewed for service users recently admitted to the home was comprehensive. This included a copy of the homes’ pre-admission assessment, the Social Services needs led assessment and any discharge summaries from the hospital. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 9 Staff had not received any training updates in mental health or dementia care within the last year, and it was agreed that an action plan to cover all the staff training needs and how these are to be met, to include timescales, would be drawn up. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The service user plans were overall up to date and identified the needs of the service users, thus providing staff with clear information of how the service users needs are to be met. Shortfalls identified should be easy to address. The management of medications has improved, but where shortfalls have been identified this could pose a risk to service users. Staff treat service users in a respectful and courteous manner, thus respecting their dignity. EVIDENCE: Service user plans were sampled on each floor. It was clear that staff had worked hard since the last inspection to bring the service user plans up to standard. Risk assessments for falls had been completed. Care plans had been formulated for all identified needs and the documentation had been reviewed monthly and whenever there was a significant change in the service users condition. There was also evidence of care plans being formulated to address newly identified needs. Wound care documentation was in place. Pressure sore risk assessments had been completed, and for one service user on the first floor, this had not been updated to reflect a broken area. In addition, the wound care documentation Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 11 required updating to reflect the fact that the wound had now healed. Other wound care documentation viewed was up to date, comprehensive and clear, and showed the progress made in wound healing. Records of the pressure relieving equipment in use for each service user were being maintained. Moving & handling assessments were in place, and the equipment to be used for each service user had been identified. Continence assessments and care plans to address continence needs were in place. The assessments had not always been signed and dated and this was discussed. Nutritional screening and assessment documentation had been completed, with weights being recorded. Risk assessments and consents for bedrails had been completed, with the exception of one on the first floor, and this was discussed with staff. Staff spoken with said that they are aware of the need to complete the service user plan documentation promptly following admission to the home. Input from healthcare professionals is recorded, and this included visits from GP, Mental Health Specialists and the Tissue Viability Nurse. The home has input from the GP practice twice a week, and there are monthly review visits by the Consultant Psychiatrist and Psychologist. The CSCI Pharmacist Inspector carried out an inspection on 19/04/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were seen caring for service users in a gentle and courteous manner, and were very patient with service users, gently encouraging them in their day-today routines. Service users have their own clothes, but it was noted that several service users on the ground floor did not have any socks or stockings on, and staff explained that this was due to lack of supply. Supplies were found in the laundry room and the Manager Designate said that this would be looked into and addressed. Apart from this service users were well groomed and dressed, and looked content. Several service users were in bed at the beginning of the inspection and staff said that service users get up when they wish. Visitors spoken with expressed their satisfaction with the home and felt that their relatives were being well cared for. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The activities provision is currently limited, thus not meeting the service users individual interests. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. Information regarding advocacy services is available, thus ensuring service users rights and interests are upheld. The meals in this home offer variety and cater for special dietary needs. EVIDENCE: The home currently has an activities co-ordinator employed for 14 hours a week. The Manager Designate said that he is in the process of employing a second activities co-ordinator so that there is appropriate activity provision in the home. This standard will be reviewed at the next inspection. Service users can receive visitors in their bedrooms or in one of the communal lounges, whichever they prefer. Visiting is encouraged and visitors spoken with said that they are made welcome at the home. The home has written to all representatives to provide information regarding ‘Care Aware’ Advocacy services. All service users are on the electoral role, and voting is arranged as appropriate. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 13 The kitchen was clean and tidy. Foodstuffs were being appropriately stored. Up to date cleaning records, temperature recordings, delivery records and risk assessments for safe practices were in place. The home has a 4 week menu and there are choices available. At the time of inspection the service users choices were not being recorded. It is acknowledged that the service users make their choice at the time of the meal and not in advance. Also the menu board on the ground floor needed cleaning so that the current menu could be written up. These points were discussed at the time of inspection. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has a clear complaints procedure, thus service users and their representatives can have their concerns listened to and addressed. Adult Protection procedures are in place, thus safeguarding service users. EVIDENCE: The home has a clear complaints procedure. No complaints had been received since the last inspection. One POVA issue had been investigated since the last inspection and this had been managed in line with the Hillingdon Safeguarding Adults procedures. Staff spoken with said that they would report any concerns. Staff had not received any recent POVA training updates, and this needs to be addressed. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23 & 26 The home is maintained in good decorative order and was clean, providing a homely environment for service users. Bathing and shower facilities are in place, but are not fully utilised to benefit the service users. EVIDENCE: The Inspector carried out a tour of the home. There was evidence of redecoration of service users bedrooms. Redecoration of the corridors and communal rooms was to commence on 20/04/06 in line with dementia research colour schemes. Documentation to record any repairs in each department has been formulated so the maintenance man can check these records and address them promptly. The bathroom facilities were clean and tidy. One assisted bath was not functioning properly and the servicing engineer was called and attended on the day of inspection. The shower room on each floor was being used as storage, and a commode pot and service users towel had been left in the ground floor shower room, which were cleared at the time of inspection. The sluice rooms were also being used as storage areas, and this needs to be addressed. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 16 All the bedrooms are single rooms. Those viewed were personalised and service users looked comfortably accommodated. The home was overall clean and smelled fresh. Some non-service user areas did require cleaning. The laundry room was viewed. One area by the sink was very untidy and the COSHH cupboard was unlocked. Personal clothing items viewed in individual baskets were labelled. There were containers of unmarked clothing being stored, and this included socks and pop socks (see standard 10). A review and sort out of items being stored in the laundry is strongly recommended. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The home is appropriately staffed to meet nursing and care needs, however the shortage of ancillary staff could pose a risk to service users. There are not the levels of staff with adequate training, thus service users needs may not always be met. Shortfalls in staff employment records pose a risk to service users. EVIDENCE: At the time of inspection the two floors were appropriately staffed with nursing and care staff to meet the needs of the service users. Staff spoken with said that generally the staffing is being maintained at an acceptable level to meet service users needs. It was noted that although staff were busy throughout the inspection, they appeared to have time to spend with the service users and complete their work. The Housekeeper was the only cleaner in the home, and the weekend cleaner is often covering the position of kitchen assistant, and this was evidenced on the kitchen roster viewed. The activities co-ordinator was covering for the cook on the day of inspection. The Manager Designate said that he is taking action to address these shortfalls. Care staff are to be enrolled on NVQ in care training in May 2006. In the records viewed, there was evidence that one carer had undertaken orientation induction training. All new staff must undergo recognised induction and foundation training and this needs to be recorded. An action plan to address all training needs is to be drawn up with timescales for completion. The staff training records did not show that staff had received a minimum of 3 days paid Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 18 training per year, and it is important that staff receive adequate training to provide them with up to date knowledge and skills to meet the needs of the service users. Staff employment files were viewed. In two instances no references were seen and in one instance only one reference was available. This is a repeat finding and the CSCI had been informed that this had been addressed. An immediate requirement was issued at the time of inspection, and this situation needs to be addressed as a matter of priority. Correspondence has been received since the inspection, and ongoing work is being done to bring all the staff employment records up to date. Thereafter robust systems must be in place to ensure that correct recruitment practices are always followed. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 37 & 38 and aspects of 36. The Registered Manager has a good understanding of the areas in which the home needs to improve. Systems for the management of service users monies are in place and secure facilities are available. Record keeping had shortfalls in some areas that could pose a risk to service users. Although overall systems for the management of health and safety throughout the home were good, shortfalls identified could potentially pose a risk. EVIDENCE: The Manager Designate had been in post for 2 weeks. He is a first level nurse with a mental handicap qualification. The Manager Designate is aware of the need to undergo a management qualification to NVQ level 4 or the equivalent. Staff spoken with said that the Manager Designate had taken time to speak with them and did regularly visit the floors to keep up to date with what was going on. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 20 Quality assurance systems will be viewed at the next inspection. Records of service users monies held at the home were viewed and checked for 3 service users at random, and were found to be correct. Computer records for receipts and expenditure were available for all service users for whom monies are held. Work has and is taking place for the Local Authority responsible for placing some of the service users to take responsibility for their monies. The Manager Designate said that he is meeting individually with each member of staff and that a system of supervision for all staff will be put in place. It was agreed that this standard would be revisited at the next inspection. Shortfalls identified in the staff employment records could put service users at risk. The administrator and Manager Designate are both working hard to put all the records in order, however additional input from Southern Cross Healthcare should be strongly considered, as problems have built up over previous months, and additional help from staff with relevant experience is required to address the current problems and ensure systems are in place to maintain records in good order in the future. Staff training in moving & handling plus first aid had been undertaken recently. It was agreed that the training programme to be drawn up with timescales for completion would include all areas of statutory training. The maintenance records were viewed and these were up to date and clear. Information on the inspection questionnaire provided by the home indicates that servicing for the gas installations in the home is overdue, having last been done in 2004. Other servicing record information was up to date. Fire drills for day staff had been carried out twice in the last year, and no fire drills for night staff had been recorded since 2004. Some gaps were noted in the completion of the fire risk assessment for 2006 and this was to be addressed. Risk assessments for safe working practices were in place. Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 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 3 X 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 X 3 X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 3 2 2 Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 22 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 OP4 Regulation 18(1) Requirement All staff must undergo mental health and dementia care training and be able to meet the specialist needs of service users. An action plan with timescales for this training must be formulated and a copy forwarded to the CSCI. Adequate funding to facilitate this training must be available. (previous timescale 01/03/06 not met) Wound care documentation must accurately reflect the condition of the wound and its progress. Bedrail assessments must be completed prior to use to identify the appropriateness of their use. That the clinical room temperature is maintained below 25 degrees by installing air conditioning. That the clinical room is kept clean and tidy. Medicines must be administered as prescribed. If not administered then the correct endorsement must be used. Medicines must be recorded accurately when administered. DS0000010927.V286667.R01.S.doc Timescale for action 01/06/06 2. 3. 4. OP8 OP8 OP9 17 13(4) 13(2) 01/06/06 01/06/06 01/07/06 5. 6. OP9 OP9 13(2) 13(2) 01/05/06 01/05/06 7. OP9 13(2) 01/05/06 Cedar House Version 5.1 Page 23 8. OP9 13(2) 9. 10. OP9 OP12 13(2) 16(2)(m) (n) 11. 12. 13. OP15 OP18 OP21 17(2) 13(6) 23(2)© 14. OP21 23(2)(l) 15. OP26 13(3) 16. 17. OP26 OP27 23(2)(d) 18(1)(a) 17. OP28OP30 18(1) Risk assessments must be updated for service users with swallowing difficulties and consent obtained where appropriate. The correct professional devices for finger pricking must be used. There must be an activities programme in place to meet the needs of the service users, with staff appropriately experienced in place to facilitate the programme. A record of service users meal choices must be maintained. There must be evidence that staff have received training in safeguarding adult procedures. The bath and shower facilities must be maintained in working order and be available for use by service users. There must be adequate storage within the home. Sluice rooms must not be used for this purpose. The liquid dosing system in the laundry must be repaired. COSHH products must be locked away. All areas of the home must be maintained in a clean condition. There must be appropriate numbers of staff employed at the home at all times to meet the needs of the service users and maintain the home in good condition. There must be evidence that all new staff complete induction and foundation training. 50 of care staff must be trained to NVQ level 2 in care or the equivalent. An action plan with timescales must be formulated to evidence how this will be achieved. Adequate funding to facilitate the training must be available. DS0000010927.V286667.R01.S.doc 01/06/06 01/07/06 01/07/06 01/06/06 01/07/06 01/06/06 01/06/06 26/05/06 14/05/06 01/06/06 01/06/06 Cedar House Version 5.1 Page 24 18. OP30 18 19. OP29 17 20. OP38 18 21. OP38 23(2)(b) (d) 23(4) 23(4) 22. 23. OP38 OP38 (previous timescale 01/03/06 not met) All staff must receive a minimum of 3 paid days training per year, and there must be evidence available to support this. (previous timescale 01/04/06 not met) Staff records must include all the information required under Schedule 2 of the Care Homes Regulations 2001. Immediate requirement issued. (previous timescale 20/01/06 not met) All staff must undergo training in health & safety topics at intervals required by relevant legislation. An action plan to with timescales for completion must be drawn up and a copy forwarded to the CSCI. There must be evidence that all equipment and installations are serviced within required timescales. Fire drills must be carried out at required intervals, to include every 3 months for night staff. The fire risk assessment must be up to date and complete. 01/08/06 05/05/06 01/06/06 01/06/06 01/06/06 01/06/06 Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 25 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 OP8 OP10 Good Practice Recommendations All service user plan documentation should be signed and dated at the time of completion. The issue with providing service users with socks or the equivalent should be reviewed and satisfactorily addressed, so that there is an adequate supply for all service users who require them. The menu boards should be kept clean and provide clear information regarding the daily meals. The unmarked clothing in the laundry should be sorted and action taken to identify the owners wherever possible. Thereafter a system to prevent such a problem in the future should be introduced. 3. 4. OP15 OP26 Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cedar House DS0000010927.V286667.R01.S.doc Version 5.1 Page 27 - 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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