Inspection on 04/01/06 for Cedar House

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 19/04/06

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 4th January 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.V275296.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.V275296.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 Mrs Vidawain Kitsonia Ajah 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.V275296.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. 2nd August 2005 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 service user areas on two floors and services and staff areas on the third floor. 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 activities co-ordinators in post. 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. Cedar House DS0000010927.V275296.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 6 hours was spent on the inspection process. The Inspector carried out a tour of the home, and inspected service user plans, staff records, financial records, maintenance and servicing records. 8 service users, 6 staff and 5 visitors were spoken with as part of the inspection process. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia or mental health care needs. At the time of inspection the home had a Manager Designate and a Deputy Manager in post, both of whom were present. The Operations Manager also attended the home for part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide require updating to reflect the current management of the home. Some shortfalls noted in the service user plans and the management of medications should be easily addressed. Staff records require more robust management to ensure all information required under the Care Homes Regulations 2001 is obtained. The system for staff supervision is under review. The main area of concern is the lack of investment in staff training. Shortfalls in training provision were noted in several areas and this needs to be addressed as a matter of priority. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cedar House DS0000010927.V275296.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.V275296.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, 2, 3, 4 and 5 The home does not provide intermediate care. The information provided to service users and their representatives about the home requires updating to provide them with current information. Written agreements are available for service users, providing clear information about the services provided. Staff require training input to ensure that they have the knowledge to meet the specialist care needs of the service users. Service users are assessed prior to admission to ensure the home can meet their needs. Prospective service users and their representatives are encouraged to visit the home thus ascertaining if the home is suited to them. EVIDENCE: The home has a Statement of Purpose and a Service User Guide. Both documents are to be updated to include management details. The Manager Designate said that copies of the updated Service User Guide would be given to service users and/or their representatives, as appropriate. Copies of the standard contract were seen, and these are comprehensive and give clear terms and conditions. Contracts are drawn up for all service users. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 9 Service users are assessed prior to admission. A copy of the new preadmission assessment document in use was seen and met this standard. The home provides nursing care for service users with dementia and/or mental health care needs. There was no evidence of recent training in mental health or dementia care and the importance of staff training in these areas was discussed. The Manager Designate agreed to draw up an action plan to show how this shortfall was to be addressed. Clear information in respect of the care for service users with differing religious and cultural needs is available to staff. The Manager Designate said that prospective service users and their representatives are encouraged to visit the home prior to admission. Short visits to include a meal, and overnight visits can be arranged. The Manager Designate said that emergency admissions are avoided where possible, but should this be necessary, a pre-admission assessment would always be carried out to ensure that the home can meet the service users’ needs. Cedar House DS0000010927.V275296.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 and 10 Overall the service user plans were comprehensive and up to date, providing staff with a clear picture of each service users needs. Shortfalls identified should be easy to address. Medications are generally well managed in the home, however shortfalls identified could potentially place service users at risk. Staff are courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy and dignity. EVIDENCE: New service user plan documentation is being introduced throughout the home. New service user plans had been formulated and staff were in the process of transferring from the old documentation to the new. Overall the documentation viewed was comprehensive and gave a good picture of each service users needs. Care plans reflected the service users mental health/dementia care needs. A fall for one service user was tracked and clear documentation was in place, with the risk assessment for falls requiring updating to reflect the fall. Some of the service user plans viewed had not been updated monthly, and these shortfalls were discussed at the time of inspection. It was acknowledged that these issues should be easily resolved once the new documentation is fully implemented. Service users’ representatives had signed assessments viewed. It was noted that space for Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 11 signatures had not been provided on the new care plan documentation, and the Manager Designate said that appropriate action would be taken to evidence the involvement of the service user and/or their representative in the formulation and review of the service user plans. Assessments for pressure sores and wounds were in place. In one instance the assessment did not accurately reflect the service users skin condition. Care plans for wounds were in place, and again, for one service user this had not been updated to reflect the improvement in the wounds. Wound care treatment was recorded but review was needed to ensure that the documentation fully reflected the condition of the wounds. Pressure relieving equipment was seen in use in the home, and the need to evidence the equipment in use for each service user in their records was discussed. Assessments for moving & handling were in place. The specific moving & handling equipment to be used for each service user had not been identified on the assessments, and this was discussed. Assessments for continence and for nutrition had been completed and where needs were identified care plans had been formulated. There was evidence of weekly weights being carried out where weight loss or the potential for weight loss due to the service users condition had been identified. Risk assessments and written consents for the use of bedrails were available in the old documentation and the Manager Designate said that action would be taken to ensure this information was contained clearly in the new documentation. There are two GP’s who provide medical cover for the home, plus there are monthly visits from the Consultant Psychiatrist and Consultant Psychologist. Evidence of input from other healthcare professionals was seen. The Manager Designate said that he was aware of the service users’ entitlements to NHS services. Medication records were sampled for each floor. A photograph plus allergy and medication compliance information was available for each service user. There was evidence of regular medication audit inspections by the dispensing pharmacist, plus the Deputy Manager also carries out audits. Controlled drugs were securely stored and records were accurate and up to date. Medication administration had been fully signed for. Receipts of medications to include the regular monthly supply plus additional medications, for example, antibiotics, ordered mid-month, had been recorded, with the exception of medications brought in from home with a new service user, and this was discussed. Where medications had been omitted for any reason, letter codes had been used. For one service user the code ‘F’ had been identified for two different reasons, and the need to have a separate coding for each reason for omission was discussed. Dates of opening had been recorded on liquid medications. Some prescription creams were being stored in service users rooms, and the need to store them securely in the clinic room was discussed. One topical cream had been labelled ‘as directed’ and this was to be reviewed with the GP to include full administration instructions. A new disposal of medications policy was in place. The storage of medications awaiting disposal was discussed and action was to be taken promptly to ensure these are securely stored at all times. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 12 Registered nurses carry out all medication administration. Issues regarding the maintaining of prescription pads on the premises are under review in line with awaited new legislation and storage is secure. Staff address service users in a courteous and gentle manner. Service users clothing is individually labelled. Service users spoken with that were able to express an opinion said that they were happy at the home and others appeared content. There was a good atmosphere on both floors. Visitors expressed their satisfaction with the care provision at the home. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 13 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 and aspects of 15 The home is aware of the need to provide service users with activities they are interested in, to keep service users as active as they can manage. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. Service users are encouraged to exercise their independence wherever they are able, to maintain their quality of life. The meal provision is good offering choice and catering for special dietary needs. EVIDENCE: The home has two part-time activities co-ordinators, and the Manager Designate said that the management of activities is being reviewed to introduce small group and individual activities, in accordance with service users abilities. Care plans for social and leisure activities were in place, to include information regarding service users individual interests. An up to date activities programme was on display in the home. The home has an open visiting policy and anyone wishing to visit after 9pm is asked to ring the home first to inform them for security purposes. Visitors spoken with said that they are made welcome at the home. Service users can receive visitors in the privacy of their own rooms. The Manager Designate said that should any issues regarding visiting arise, he would manage this effectively and ensure clear records are kept. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 14 At the time of inspection no service users were managing their own finances. The home has input from two advocacy services, with one being specifically for financial purposes. Service users are encouraged to bring in personal possessions and some of the rooms viewed were personalised. Service users can have access to their records if they so wish. Service users were seen enjoying the lunchtime meal. A choice is available and this is recorded at the time of the meal. The Inspector sampled one lunch option and the meal was well presented and tasty. The situation regarding the food budget identified at the last inspection had been promptly addressed and this improvement has been maintained. Information regarding cultural and religious needs in relation to nutrition is provided. Special diets to meet service users medical needs, for example, diabetes, are provided. The menus and food provision reflect the needs of the service users. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 15 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, 17 and 18 The home has a satisfactory complaints system with evidence that concerns are listened to and acted upon. Service users rights are protected and service users are able to exercise their legal rights directly if they so wish. Staff have knowledge and understanding of adult protection issues, thus protecting service users from abuse. EVIDENCE: The home has a clear complaints procedure, which contains timescales for the management of complaints and contact details for the CSCI. There had been one complaint since the last inspection and the documentation was clear and showed the progress of the complaint. The home has access to two advocacy services for service users. Service users are on the electoral role, and if a service user wished, appropriate arrangements would be made to allow them to participate in the electoral process. One adult protection issue has been addressed since the last inspection. The home follows the Hillingdon Safeguarding Adults procedures, and clear guidance to managers is provided. The Operations Manager said that the company has access to an Adult Protection Advisor Consultant also. Staff spoken with were clear about adult protection procedures and said that they would report any concerns of this nature. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 16 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, 24, 25 and 26 The home is maintained in a good decorative state, thus providing a homely environment for service users. Bathing and shower facilities are in place, and review is taking place to ensure service users needs are fully met. The home was clean and systems for the prevention of the spread of infection were being adhered to, thus safeguarding service users. EVIDENCE: A copy of the programme of maintenance and refurbishment has been forwarded to the CSCI, which shows evidence of works identified and completed. A tour of both floors was carried out, and there was evidence that several rooms had been redecorated in recent months. The grounds are tidy and well maintained. The maintenance man carries out weekly maintenance checks of areas of the premises, with a monthly full premises check, and records are kept. The bath and shower areas were clean and tidy. The assisted shower facility on the first floor was not being used, and plans to change the use of this to Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 17 provide an additional assisted bathing facility are under consideration. One shower attachment in a bathroom was broken and required replacing. The bedrooms viewed were well maintained. The flooring in one bedroom is to be replaced due to unsuitability. The home has 12 electric profiling beds, and 4 more have been ordered. Several of the other beds are manually adjustable, and the Manager Designate said that he is aware of the need to ensure that adjustable beds are provided for all service users with moving & handling needs. The home was pleasantly warm throughout. Checks of the hot water to include storage, distribution and outlet temperatures, plus cold water temperature checks are carried out and recorded. The lighting throughout the home was satisfactory. Emergency lighting is provided and there was evidence of regular checks for maintenance purposes. Window restrictors are in place, allowing windows to be opened to a safe width. The laundry is sited on the second floor, away from service user areas. Policies and procedures for infection control are contained in the draft Health & Safety documentation. The laundry was clean and tidy. Hand washing facilities were available in all areas where service users, staff and visitors may require to wash their hands. Protective clothing to include aprons and gloves were seen in areas throughout the home. There is a sluice facility situated on each floor. The washing machines are industrial and have sluice programmes for the cleaning of soiled laundry. The home was clean and the domestic staff were dealing effectively with any localised odours noted. Systems were in place for the flushing through of the water facilities in vacant rooms and unused facilities, to minimise any risk of legionella. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 18 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 and 30 The home is appropriately staffed to meet the current needs of the service users. Training, both for induction and foundation, plus NVQ, needs to be increased so that staff have the skills and knowledge to meet service users needs. Staff recruitment is generally robust, but shortfalls could potentially place service users at risk. EVIDENCE: At the last inspection issues with staff shortages were identified. This has been reviewed and addressed. Staff and visitors spoken with commented on the improvement of staffing levels. Where additional input is required to meet service users needs, this is provided. Action has also been taken to ensure that service users are accommodated on the floor most appropriate to meet their needs, and this has meant that the staffing is more effective. The home was clean and tidy and appropriate numbers of domestic and ancillary staff are employed at the home. The Manager Designate reported that 9 care staff have an NVQ in care at level 2 or above. The Deputy Manager has been working to access NVQ in care training for care staff. An action plan to show how the home is to have 50 of the care staff trained to NVQ level 2 or the equivalent is to be formulated, with timescales. Adequate resources to fund NVQ training must be provided. The Inspector sampled staff employment records as part of the inspection process. Photographs were not seen on the files viewed. Health questionnaires Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 19 had been completed. One application form completed did not request the reason for leaving previous employment. Criminal Records Bureau checks and POVA first checks had been carried out. Contracts of employment were available. In one instance, the need to clarify the employees’ most recent previous employment was discussed, and this has since been addressed. Only one reference had been received for one employee and this was to be addressed. A matrix of staff employment records has been forwarded to the CSCI following the inspection and action is being taken to address any shortfalls identified. Copies of the General Social Care Council code of conduct have been obtained for all staff, and the registered nurses abide by the Nursing & Midwifery Council code of professional conduct. Induction and foundation training programmes are in place, and these meet the Skills for Care (formerly TOPSS) core standards. The need to evidence that all new staff complete induction and foundation training was discussed. The training records did not show that all staff receive a minimum of 3 paid days training per year, and an action plan to show how this is to be addressed needs to be formulated. Again, funding needs to be provided for staff training. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 20 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, 33, 35, 36, 37 and 38 The Manager Designate has the knowledge and experience to manage the home. Systems are in place for the ongoing auditing of the home, for quality assurance monitoring and progress. Service users finances are well managed and thus safeguarded. Staff supervision is under review and a robust system will promote a forum for discussion and professional development. The home is well maintained, thus providing a safe environment for service users. However, the completion of mandatory health & safety training by all staff had not taken place, which could pose a risk to service users and staff. EVIDENCE: The Manager Designate is a first level registered nurse with a mental health qualification. He also has a diploma in higher education nursing sciences and an NVQ level 3 in management. He was aware of the need to complete the NVQ level 4 or equivalent in management. The Manager Designate has undertaken a variety of training courses relevant to the needs of the home and the service user group. The Manager Designate is responsible for one home Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 21 only, and stated that his job description enables him to take responsibility for fulfilling his duties. There are clear lines of accountability within the home and with the external management team. There was evidence of auditing processes in several areas, for example, pressure sores, accidents and medications. The maintenance man carries out health & safety audits. Satisfaction questionnaires are sent out from head office to service users representatives, and are also available in the reception area of the home. Documentation in respect of a development plan for quality assurance was available, and the Manager Designate said that this would be updated for the current year. Policies and procedures are updated corporately and then forwarded to the homes. The home has current employers liability insurance, and the company has corporate insurance to cover the business aspects of the home. Records of personal monies held for service users were viewed. Small amounts of cash are kept for service users and clear records of all income and expenditure, with receipts for expenditure, are kept. Due to changes in management and in administration staff, arrangements to provide identified signatories for necessary accounts are being put in place. The home has a safe facility. The Manager Designate has reviewed the supervision systems for staff and has carried out informal supervision sessions with the registered nurses. The need for supervisors to be trained to carry out supervision competently has been identified and the Manager Designate is in the process of addressing this. A programme of staff supervision will then be formulated and put in place. Ongoing supervision as part of the day to day management of the home is in place. Records are stored securely in the home. Any shortfalls identified have had requirements set under those particular standards. The training records viewed did not evidence that all staff had received mandatory training to include health & safety topics. The need to ensure that all staff working in the home are up to date with mandatory training was discussed. The maintenance man carries out monthly safety checks on equipment and on all rooms within the home. Checks in line with fire safety are also carried out. Written evidence is available in the home. Fire drills for day and night staff had been carried out, and were due for updates, which the Manager Designate said he would address. Some of the maintenance and servicing records were viewed at random and those viewed were up to date. A list of the servicing dates has since been forwarded to the CSCI. The Manager Designate is aware of the need to ensure all servicing is kept up to date and the information to evidence this is to be easily accessible. The home has draft Health & Safety documentation, to include generic risk assessments for safe Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 22 working practices. Copies of the relevant assessments are to be placed in the kitchen and laundry areas, for ease of access for the staff in these areas. Accidents are recorded and reported, and Regulation 37 notifications are forwarded in line with CSCI guidance. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 23 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 2 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 3 18 3 3 X 2 X X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 2 Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 24 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 OP1 Regulation 4 Requirement The Statement of Purpose must be updated so that it reflects the current management of the home. A copy must be forwarded to the CSCI. The Service User Guide must be updated and copies distributed to service users and/or their representatives and the CSCI. 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. The service user plan must be reviewed monthly and whenever the service users condition changes. Risk assessments for falls must be updated following any falls. Documentation to include wound care must be kept up to date. (previous timescale of 01/09/05 not met) DS0000010927.V275296.R01.S.doc Timescale for action 01/02/06 2 OP1 5 01/03/06 3 OP4 18(1) 01/03/06 4 OP7 15, 17 01/02/06 5 6 OP7 OP8 13(4) 17 05/01/06 20/01/06 Cedar House Version 5.1 Page 25 7 OP8 17 8 OP8 13(5) 9 10 OP9 OP9 13(2) 13(2) 11 12 OP9 OP9 13(2) 13(2) 13 14 15 OP9 OP21 13(2) 23(2)(c) 18(1) 16 18 Assessments and documentation for wounds must accurately reflect the condition of the wound. The pressure relieving equipment in use for each service user must be clearly identified in the service users plan. The specific moving & handling equipment to be used must be identified in the service users individual service user plan. All receipts of medications into the home must be recorded. Any codes used for the omission of administration of a medication must be clearly identified, with each code in use having an individual reason recorded. All prescription medication to include creams must be securely stored. Instructions for use must be clearly recorded and ‘as directed’ must not be used for any medication administration instruction. All medications to include those for disposal must be securely stored. The shower attachment must be replaced. 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. All staff must receive a minimum of 3 paid days training per year, and there must be evidence available to support this. DS0000010927.V275296.R01.S.doc 20/01/06 20/01/06 05/01/06 05/01/06 05/01/06 20/01/06 04/01/06 20/01/06 01/03/06 01/04/06 Cedar House Version 5.1 Page 26 17 OP29 17 18 OP36 18 19 OP38 18 Staff records must include all the information required under Schedule 2 of the Care Homes Regulations 2001. Staff facilitating supervision must be trained and competent to do so. All staff providing care must receive formal supervision a minimum of 6 times per year, and this must be implemented. All staff must undergo mandatory training at intervals in line with current associated legislation. A record to evidence this must be kept. (previous timescale of 01/09/05 not met) An action plan to address shortfalls must be drawn up and forwarded to the CSCI. Adequate funding must be made available to ensure that staff receive the training required to enable them to fulfil their role. 20/01/06 01/04/06 01/02/06 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 OP7 OP38 Good Practice Recommendations A system for evidencing service user and/or representative involvement in the formulation and review of service user plans should be implemented. It is strongly recommended that copies of the risk assessments relevant to areas such as the kitchen and the laundry be kept in these areas for ease of referral. Cedar House DS0000010927.V275296.R01.S.doc Version 5.1 Page 27 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.V275296.R01.S.doc Version 5.1 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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