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Inspection on 13/12/05 for Cedar House Nursing & Residential Home

Also see our care home review for Cedar House Nursing & Residential Home for more information

This inspection was carried out on 13th December 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Since the manager`s appointment, sustained progress has been made in developing care plans and assessment documentation. She has generally been effective in meeting those requirements which fall directly within her remit and so improving some aspects of the service (see above). This is commended. Work to the fabric of the building continues with both internal and external redecoration. However, see also below. There has been an increase in the numbers of locks fitted to residents` bedroom doors so that they if they are able, and wish to do so, they may hold keys (although the type obtained has not provided for a standard master key to all locks). The manager has also been purchasing over a gradual period, more lockable facilities for bedrooms so that residents may keep private and personal items securely if they wish to do so. (Budgetary constraints have made progress slower than she would wish.)

What the care home could do better:

The management team and care staff work hard to deliver a good service. However, there are issues which are beyond their control because of the expenditure needed. This includes the provision of locks and lockable facilities, redecoration and replacement of floor coverings. (In some areas treatment of the underlying floor surface is likely to be needed because of continence difficulties and poorly sealed existing coverings.) Work recommended by the fire authority is in progress but needs completion so that the home meets the required standards. Staff work hard and show great goodwill in delivering outings and some seasonal activities for residents. However, on a day-to-day basis the providers` insistence that only minimum care staffing levels are maintained, and the need for carers to assist in completion of residents` laundry, mean that they have little time to improve this area of care. There is insufficient domestic cover to be able to maintain standards of cleanliness and to manage the laundry, which has increased over time with the increasing dependency of residents. There have been unacceptable delays in the providers replacing or repairing essential items of equipment, despite issues being reported promptly by the manager and "chased up". This includes the wheelchair lift, which was out of action for a period of five weeks. The washing machine also broke down and was neither repaired nor replaced for three weeks. The providers must take account of the impact of these failures on both residents and staff.

CARE HOMES FOR OLDER PEOPLE Cedar House Nursing & Residential Home Church Road Yelverton Norwich Norfolk NR14 7PB Lead Inspector Mrs Judith Huggins Announced Inspection 13th December 2005 09:30 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 Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 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 Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cedar House Nursing & Residential Home Address Church Road Yelverton Norwich Norfolk NR14 7PB 01508 494207 01508 495602 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) Cedar House (Norfolk) Limited Ms Sharon Marie Hart Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate a maximum of twenty-six (26) older people of either sex, not falling into any other category. 28th July 2005 Date of last inspection Brief Description of the Service: Cedar House is a period residence, with an extension, situated beside the church in the village of Yelverton and is one of three homes in Norfolk offering nursing care, owned by Caring Homes Ltd. It is registered as Cedar House Limited to provide nursing and residential care to older people (not falling into any other category, e.g. with dementia). The main house is on 3 floors served by staircases and a lift. The majority of service user accommodation is on the ground and first floor. The care home’s offices and 2 service users’ rooms are situated on the upper floor. On the first floor the landing area has split levels and four bedrooms are accessed by a separate wheelchair lift. Cedar House stands in pleasant surroundings, having a large garden that is mostly laid to lawn and is surrounded by mature trees. The location is rural, to the south east of Norwich, and there are no amenities in the immediate area. Access to the nearest shopping and social centre is by private car or by a bus service the regional manager says runs three times daily. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and lasted nine and three quarter hours. Most parts of the inside of the home, including several of the bedrooms, were seen. During the course of the inspection, one relative, the manager, and four residents were spoken to. One visitor was spoken by telephone. Two staff members were interviewed and one spoken to with the manager. Comment cards were received from one visiting health professional and two other visitors to the home. Where appropriate, the views expressed are included in the report. Other information was taken from the questionnaire completed by the manager, and from records, including care plans, sampled on the day. Three care plans were looked at in detail, and others checked at random. What the service does well: What has improved since the last inspection? Since the manager’s appointment, sustained progress has been made in developing care plans and assessment documentation. She has generally been effective in meeting those requirements which fall directly within her remit and so improving some aspects of the service (see above). This is commended. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 6 Work to the fabric of the building continues with both internal and external redecoration. However, see also below. There has been an increase in the numbers of locks fitted to residents’ bedroom doors so that they if they are able, and wish to do so, they may hold keys (although the type obtained has not provided for a standard master key to all locks). The manager has also been purchasing over a gradual period, more lockable facilities for bedrooms so that residents may keep private and personal items securely if they wish to do so. (Budgetary constraints have made progress slower than she would wish.) 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 Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 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 Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 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): 3 and 6 Residents do not move into the home without having their needs assessed and being assured these will be met. The home does not offer a dedicated rehabilitation service. EVIDENCE: The information collected before admission was checked for one person admitted in October. This showed that a range of information was gathered before the admission was arranged. This information covered the areas set out in standards. As set out in regulations, a letter had been sent confirming that the home could meet the person’s assessed needs, again before they were admitted to the home. This is good practice. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 Residents’ health, personal and social care needs are set out in a plan of care. Residents’ health care needs are fully met. Residents are treated with respect. Privacy is upheld with minor shortfalls. EVIDENCE: Each care plan seen had a good range of information, and clear instructions for staff to follow in each area of care. Initial plans are discussed with residents (where they are able) or with their representatives – signatures seen. This is good practice. Discussion with the manager showed that there is some difficulty securing the involvement of representatives in reviews on a regular basis. One person’s file showed that the representative wished to be involved in monthly reviews. This has not yet happened although the manager is discussing how this might be achieved. All plans seen were regularly reviewed and updated by staff. Again, this is good practice. There is good attention to body language and behaviour where a resident’s communication has been impaired by a medical condition. There was particularly good and clear information about the arrangement of food on the Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 10 plate of one person who cannot see, and where drinks should be positioned, so that the person can maintain some independence at mealtimes. One plan does not fully reflect behavioural difficulties causing difficulties with disposal of used continence pads and the need to check the person’s room regularly, although it does make clear reference to checking other related areas. Personal care needs are properly set out, although records of care delivered do not fully support that this is given in accordance with assessed needs and care plan goals. The inspector acknowledges that one record showed that the person had no baths in November or December to date, but that a visitor confirmed that this happened, and on the day of the inspection a bath was given to the person concerned. There is evidence in care notes that conditions presenting concern are promptly referred to the GP, and that chiropody, dental and other appointments are arranged as needed. A visiting health professional is satisfied with the overall care provided. Discussion with staff shows that they understand the need to uphold privacy. However, not all WC/bathing facilities have privacy bolts fitted, and although progress has been made, not all bedrooms yet have locks and lockable facilities. Staff assisting one resident in a shared WC/bathing facility, did not make use of the “engaged/vacant” sign appropriately, to help prevent accidental intrusion. Residents’ post was seen as unopened, in pigeonholes in the hallway for relatives or residents to collect. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 11 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 Social and recreational interests and needs are not fully met as set out in care plans. Residents are able to maintain contact with family, friends and representatives. Residents are helped to exercise choice and control over their lives although this was recently severely limited for some residents due to equipment failure. EVIDENCE: Care plans and assessments reflect people’s interests and hobbies, and goals for social and recreational care. This is good practice. However, care notes do not reflect that these needs are met routinely. The manager reported that there have been considerable difficulties in recruiting someone who would be responsible for the provision of activities, although efforts have been made. The person who does hairdressing at the home provides 3 hours each week to recreational activities – although these predominantly relate to manicures and massage, based on notes seen. Reminiscence activity has taken place on limited occasions although the manager states that these are £30 per session. The budget for meeting recreational and social needs is £35 per month for all of the people in residence Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 12 Residents were all recently taken to Caistor Hall for a Christmas party, which they clearly enjoyed. There is programme of seasonal activities displayed on the noticeboard in the reception hall. Staff are to be commended for making considerable effort with this, including volunteering their services. However, two residents spoken to say that there is not much in the way of activities on a day-to-day basis, and that there used to be more. Staff say that they do not have much time during the course of their shifts, to spend encouraging, organising or supporting residents with social and recreational activities. Two relatives spoken to and completing comment cards say that they feel welcome in the home at any time, and are able to visit in private. Residents spoken to confirm that they receive visitors, and relatives were noted as present at various times of the day during the inspection. There is some flexibility of routine in terms of rising and retiring and choice of food. Rooms seen show that residents are able to bring in their own belongings. One resident is, based on records seen, encouraged to hold some personal spending monies. The wheelchair lift needed for residents on the first floor to access their rooms, where there is a split-level, has recently been replaced. However, it was out of action, according to the manager for a period of 5 weeks during which requests to property services for repair or replacement were not met. During this time residents needing the wheelchair lift were unable to come out of their rooms and make use of communal facilities or bathing/showering facilities on other floors. This significantly restricted choice and autonomy of residents affected, effectively resulting in restraint, and represents an unacceptable delay in the providers completing the necessary works. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 13 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 Residents and relatives are confident their complaints will be listened to and acted upon, within the manager’s remit. EVIDENCE: Complaints records show that these are addressed promptly. Where these relate to issues requiring additional expenditure, the manager refers them on through the management structure to head office. At the last inspection requirements were made for complaints to be dealt with, within 28 days. On this occasion, only one subsequent complaint had been received, and there was regular correspondence updating the complainant about actions taken (the resolution being dependent upon agreement from head office to replace a carpet. This was attended to during the inspection). The requirement made at the last inspection for complaints to be investigated and complainants told of the action that will be taken to address their concerns, is therefore considered met. Both relatives completing comment cards say that they know what the complaints procedure is. Two of the three residents spoken to say that they do not have any complaints. One did not respond. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 14 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, 20, 25, 26 Although maintenance work has taken place, more is needed to ensure that residents live in a safe, well-maintained environment. There are some risks to residents in communal areas, and the comfort of personal surroundings could be improved. There is room for improvement in the cleanliness and hygiene of the home. EVIDENCE: Work has been undertaken to repair the lower part of the roof, and the manager says that there have been no further problems with leaks. However, the higher part of the main roof has not been attended to. There is evidence of some water penetration with bad staining and mould growth on a wall in the top floor staff WC/store room. The manager reports that property services have visited to identify three rooms needing refurbishment as per the five-year plan, but that she has not been consulted regarding priorities. The programme for maintenance and renewal is not held in the home. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 15 Some bedrooms have wallpaper and paint that is worn, the latter flaking on the inside of window frames in some cases. In some areas, the paper is stained and dirty from dust deposited above radiators where hot air rises. One bedroom has a damaged carpet with a long tear down it, partially taped, and representing concerns for the safety of staff and the room’s occupant. These rooms might have greater priority for attention than those identified by the company’s property services. Works were being undertaken during the inspection, to meet the requirements of the fire officer following a recent inspection. These are not yet complete. They include the replacement of fire doors which do not fit properly to restrict the spread of fire. Curtains in some bedrooms were not hanging properly, with hooks and fixings broken. The manager states that these are gradually being replaced with curtain poles as the previous rails and fittings have become brittle with age. In several of these rooms, there are cracks in the ceilings. Tiles behind the sluice disinfector on the ground floor have not been repaired and replaced so that the wall can be kept properly clean and is impervious to any accidental splashes. Carpets in the dining room and corridors are coming to the end of their useful life. They are stained, despite regular cleaning, according to the manager and staff. There is insufficient space in the lounge and dining room. The manager has felt it necessary to carry out risk assessments for the safety of residents, and this involves the removal of walking aids. A resident commented that that the lounge is very full and enquired when the conservatory was to be completed as it had been “on the cards for some time” and that “it would be nice to have more space.” There have been regular occasions during the last year, when residents have not had full and free access to communal areas, where they have rooms above the ground floor. This has included a 5-week period where the wheelchair lift was out of action. Records show a total of 30 maintenance or call out visits to attend to the main shaft lift during 2005, and that some further work is recommended. This presents concerns for the long-term effectiveness of the main lift and for access by residents to all appropriate areas of the home. Requirements associated with the maintenance of the premises by the Commission have not consistently been met, and the owners have not promptly addressed the manager’s requests for urgent repairs to essential equipment. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 16 Although the standard was not inspected in full, the requirement made under standard 24, for the provision of lockable facilities has not been fully met – although progress has been made. There are areas of the home where the temperature varies considerably. Some bedrooms and en-suite facilities were agreed as cold with the manager. One shared room was noted by two inspectors as cold. A visitor commented that bedding was not of good quality and unlikely to be warm enough during the winter, in their view. There is one member of cleaning staff in post, for a total of 37 hours. One other person does some cleaning, up to 12 hours a week, but is predominantly a carer. The member of cleaning staff also attends to the laundry and with care staff helping when she is not available. The size, age and layout of the building mean that it is not easy to keep clean. The kitchen floor around the doorway, and doorframe was not clean. There were accumulations of dust on the skirting board behind the door, and on top of pipe work under the sink. The manager states that the laundry has been equipped with a replacement machine since there were problems with the last one. She says that when the machine broke down the home was without a washing machine for three weeks. Staff confirmed this was so, and that staff or the manager took washing or drying home, and care staff also had to take washing to the launderette. Where the laundry is situated also means that laundry can only be done during the daytime. This is unacceptable in that it removes care staff, operating at minimum levels, from care tasks, it presents concerns for infection control, delays the return of personal items to residents (and a relative reports that approximately 12 pairs of socks are still missing), and it relies upon the goodwill of staff to meet the provider’s obligations. Difficulties in managing the odour associated with continence difficulties are compromised where floor coverings are not properly sealed and impervious. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 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 Residents’ needs are not fully met by the skill mix of staff. EVIDENCE: The home continues to operate with care and nursing staff at the minimum level specified in the staffing notice when the home was originally registered. This is based on an historic figure devised in the 1980’s. It does not take into account the dependency levels of residents. Problems are exacerbated by the lack of ancillary staff commented on elsewhere. Although standard 30 was not fully inspected, a repeat interview with a member of staff who was very new in post at the last inspection, confirmed that there was a good understanding of a range of appropriate issues. The manager confirms that areas covered in induction are discussed with new staff so that she can be satisfied they have understood the information given. This is good practice; the requirement is not therefore repeated. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 18 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): 32, 35 and 38 As at the last inspection, residents continue to benefit from the ethos, leadership and management approach within the home. Residents’ financial interests are safeguarded. The health, safety and welfare of residents needs attention in some areas. EVIDENCE: As at the last inspection, staff spoken to feel well supported and that they can go to either the manager or the deputy if they have difficulties or issues they wish to raise. Both spoke of good teamwork and morale and say that they enjoy their work. Improvements were identified by one longer standing member of staff, who says that care staff are much more involved and have much more information than under the previous manager. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 19 There is evidence in the form of notes and notices that staff meetings are held regularly. The manager and deputy should be commended on the team spirit they have created. Records of personal monies held on behalf of residents were inspected. These show balances held and the dates and purposes of expenditure. Two members of staff sign each entry, which is good practice. However, one resident clearly manages amounts of monies independently from time to time, but does not sign the record to acknowledge that they have received the money, signatures from staff considered to be adequate. Three balances checked at random were found to be accurate and with corresponding receipts. Although not specifically inspected on this occasion, the monitoring of the home by the regional manager, on behalf of the providers, was checked. The requirement made at the last inspection regarding these visits (under standard 33) is considered met. As noted elsewhere, work has been recommended to the lift, to ensure that this remains in good working order – its continued functioning being vital to the welfare of residents as well as their safety. Also, work is in progress towards meeting the fire authority’s requirements (taking place during the inspection), but is not yet complete. The torn carpet in one bedroom presents a risk to the safety of the room’s occupant and to staff. In one other room the carpet was loose and rucked but the manager indicated that she had requested carpet fitters present on site to have a look at this. There is a good system of auditing and monitoring health and safety, and a range of appropriate servicing agreements was seen. However, there is no confirmation that the wiring in the building has been checked and certified as safe. The manager says she has taken this up with head office and received assurances but no evidence, that it was checked almost five years ago. Given the age of the building it is important the providers show evidence of the safety of the wiring. Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 2 x x x x 2 2 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 x x 3 x x 2 Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 21 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 OP10 Regulation 12(4) Requirement The registered persons must ensure that, pending fitting of suitable locks to WC/bathing facilities, “engaged” signs are used properly to prevent accidental intrusion. The registered persons must ensure that the programme of fitting suitable locks to bedrooms is completed. Outstanding requirement with timescales of March and December 2005 unmet. The registered persons must provide lockable facilities for service users to store personal effects and provide keys unless contra-indicated by risk assessment The registered persons must ensure that privacy bolts are fitted to all WC/bathing facilities. Outstanding requirement The registered persons must ensure that care needed to meet recreational and social needs is delivered in accordance with the care plan. The registered persons must DS0000015626.V264210.R01.S.doc Timescale for action 31/01/06 2 OP10 12(4) 28/02/06 3 OP10and OP24 12(4) 28/02/06 4 5 OP10 OP12 12(4) 12, 16(2) 28/02/06 31/01/05 6 OP14 23(2) 31/01/06 Page 22 Cedar House Nursing & Residential Home Version 5.0 7 OP19 23(2) 8 9 OP19andOP 16(2) 38 13(4) OP19andOP 23(4) 38 10 OP19 23(2) 11 OP19 23(2) 13(3) 12 13 OP19 OP20 and OP38 16(2) 23(2) 23(2) 14 OP26 16(2) 23(2) 15 OP26 23(2) 16(2) make arrangements to ensure that essential repairs to equipment needed for residents to access the home fully, are attended to promptly in future. The registered persons must make the necessary repairs to the main roof of the old part of the building. The registered persons must replace the torn carpet in room 21. The registered persons must complete all works identified as necessary to meet the requirements of the fire authority. The registered persons must submit a programme of work to redecorate and refurbish bedrooms in need of attention, in discussion with the manager of the home to identify priorities. The registered persons must replace tiles behind and around the sluice disinfector to ensure that the wall can be cleaned properly. The registered persons must replace worn and stained carpets. The registered persons must attend to recommended works by the lift engineers, and notify the Commission of their intentions to ensure accessibility and safety for residents. The registered persons must ensure that floors are treated and floor coverings replaced and properly sealed where these are defective and where there is odour in WC’s and en-suite facilities. The registered persons must take action to ensure that repairs to equipment needed to maintain adequate standards of DS0000015626.V264210.R01.S.doc 31/03/06 31/01/06 11/02/06 31/03/06 31/03/06 31/05/06 31/03/06 31/03/06 31/01/06 Cedar House Nursing & Residential Home Version 5.0 Page 23 16 OP27 18(1) 23(2) 16(2) 17 OP38 10, 13(4) 23(2) hygiene and cope with laundry generated, are attended to without delay in future. The registered persons must review arrangements for ancillary staff to ensure that standards of cleanliness are maintained and laundry tasks are completed without routine recourse to care staff for completion. The registered persons must provide evidence that the wiring in the building has been tested and certified as safe. 28/02/06 28/02/06 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 Refer to Standard OP7 Good Practice Recommendations The registered persons should explore further their suggestions and ideas for ensuring relatives/representatives are involved in reviews as often as they would wish. The registered persons should ensure that all identified behavioural issues, presenting difficulties for odour control and hygiene, are set out and followed up so that staff make the necessary checks. The registered persons should ensure that records fully reflect the personal care that is delivered. The registered persons should review heating arrangements to ensure these are adequate to maintain a comfortable temperature in residents’ rooms. The registered persons should obtain signatures of residents who are able to sign, when monies held on their behalf for safekeeping, are returned to them. 2 OP7 3 4 5 OP7 OP25 OP35 Cedar House Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Nursing & Residential Home DS0000015626.V264210.R01.S.doc Version 5.0 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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