Inspection on 19/07/05 for Cedardale Residential Home

This inspection was carried out on 19th July 2005.

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

Cedardale Residential Home 02/07/08

Cedardale Residential Home 06/12/06

Cedardale Residential Home 15/11/05

Cedardale Residential Home 30/11/04

Cedardale Residential Home 18/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Cedardale Residential Home Queens Road Maidstone Kent ME16 0HX Lead Inspector Ann Block Announced 19 July 2005 09:45 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 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. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cedardale Residential Home Address Queens Road Maidstone Kent ME16 0HX 01622 755338 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MGL Healthcare Ltd Mr Michael Joseph Gaetan Lisis CRH Care Home 21 Category(ies) of Dementia over 65 (21) registration, with number of places Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users between 55 and 65 of age experiencing difficulties with memory loss or a diagnosis of dementia may be admitted. 2. It has been agreed that rooms 2, 6, 10 & 11 can be shared by married couples, siblings or individuals whose needs can be evidenced as best met in a shared facility. Date of last inspection 30 November 2004 Brief Description of the Service: Cedardale Residential Care Home was first registered to care for older people in 1989. MGL Healthcare Ltd. took over ownership in April 2004 and since June 2005 has been registered to accommodate 21 people aged 55 and above who have a diagnosis of dementia. At present the home is in the transition period. Cedardale is located in a quiet tree lined residential area of Maidstone, close to shops, pubs, churches, public transport and other usual town amenities. Cedardale consists of a two storey building with a newer single storey extension. There are thirteen single and four shared bedrooms. Eight of the single rooms and all of the shared rooms have en suite toilet and washbasin. The first floor is accessed by a stair lift. The home has large landscaped gardens with car parking to the front of the house. The home employs care staff, working a roster, which gives 24 hour cover. The home also employs other staff for catering, domestic and maintenance duties. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of an announced inspection carried out on the 19th July 2005 between 9.45 am and 5.40 pm. The commission was represented by regulatory inspector Ann Block. Feedback was provided to the manager during and at the end of the inspection. A number of visitors, residents and staff spoke with the inspector, mainly in private. Some residents experience levels of confusion which prevent direct questions and answer. The location of the small lounge used as a base for the inspection gave opportunities to observe interactions during the day. This report includes evidence and judgements made through conversation, observation, records and previous inspection reports. Throughout the inspection, there was a relaxed atmosphere with residents going about their business supported discreetly and courteously by staff. All those spoken with said they were very happy with the service provided at the home, complimented the management, especially Michael Lisis the Registered Manager, and were glad they had chosen Cedardale to live or work. As part of the inspection comment cards were made available to residents, relatives, health professionals and visitors. Responses were unanimous in their satisfaction with the service provided. Comments included: The home provides a high standard of care with very dedicated, patient staff An excellent care home, a very happy establishment, nothing is too much trouble, my mum is being looked after very well The staff have been very receptive to advice and care needs, they have a good relationship with our clinical staff and ring for advice on good standards of care The staff are very receptive to suggestions and willing to try other approaches. Cedardale has a very friendly atmosphere and the staff are always helpful Whilst there are some areas needing further action in respect of good practice, these are to be set against a service which demonstrated excellent care and consideration for older people and a willingness to explore any opportunities to improve service provision. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection? The needs of many older people already living at Cedardale have been recognised and a change in registration has been made. The statement of purpose includes information about the review of care plans to ensure current needs are known. Care plans have been developed to give detail of individual need and assessments. Further development is planned. Risk assessments to promote the safety of residents have been implemented with further work planned. As part of these risk assessments, radiators which posed a risk of burns to residents have been covered. Safety is further promoted as residents using a wheelchair are required to have footplates in place. To identify ways of improving the service, a quality assurance system is being implemented. To safeguard residents against the risk of abuse staff work to the Kent & Medway adult protection procedures. Photographs of staff and residents have been taken and are largely in place. Dignity is maintained by proper display and storage of personal information. Residents’ money is better safeguarded by being held individually. The accident record now maintains confidentiality. Staff are better able to meet residents’ needs as more staff have undertaken client specific and general training. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 7 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. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 & 6 Sound systems are in place for residents to move into Cedardale confident in the knowledge that the home will be suitable for them. EVIDENCE: A new statement of purpose has been drawn up in line with change of registration to care for people with dementia. The statement of purpose is presented in a clear, comprehensive and informative manner. Each resident or their representative has a contract, some having the updated contract between MGL and themselves, others having an earlier contract. Some minor adjustments to the MGL contract would offer residents more written security of residency, particularly in relation to their rights. It is to be noted that residents’ rights were fully upheld in practice. Residents spoke of meeting the manager and senior carer or key careworker before they were admitted. One relative expressed their gratitude that the manager and key staff travelled to Gloucestershire to carry out an assessment to make sure the resident would be best placed at Cedardale. Where possible information from other professionals is obtained. Input from family and friends will be taken into account. Information gathered before admission is used as the basis for the care plan. As confirmed by a family and stated in the statement of purpose, prospective Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 10 residents may visit the home and stay for a night if they choose. A family had noted that care was taken to introduce residents to each other whom it was felt would be compatible. One resident was helped to settle by having her room laid out the same as it had been at home. Respite care is available, room permitting. Often this is used as a gentle introduction to permanent care. Every effort is made to ensure that Cedardale will be right for the resident and for them to be as happy as possible there. In line with the recent registration for people with dementia, staff skills and training are being arranged to meet the needs of residents both being admitted and developing dementia/confusion. Staff spoke of increased confidence in their skills in working effectively with people with dementia. Certainly, relatives felt that staff understood the residents well. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 & 11 Residents are well cared for throughout the stages of older age and potential deterioration in mental and physical abilities. EVIDENCE: A lot of work has gone into setting up readable, well set out and informative care plans. Senior staff welcomed suggestions to further develop care plans. Work is needed to ensure key information is available so that each resident has a care plan which gives good, consistent and easily accessible detail of relevant areas of care. A senior carer spoke of thinking of setting up ‘Getting to Know you’ booklets for each resident which would contain details of their history, likes and dislikes, key contacts etc. As is often the case in smaller establishments, staff possessed more information than recorded in care plans and spoke of how they would share this at handover. Care plans seen contained a section for risk assessments which gave action to take to reduce or remove the risk. Where an incident had occurred during a settling in period, recorded action had immediately been taken to reduce the risk. To further improve safety, action should similarly be taken in response to recordings on the daily events sheet. Residents’ health is promoted with appointments made with local health services, including specialist psychogeriatric services. Residents were registered with a local GP who was reported to be supportive, Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 12 including support for the change of category of registration. Residents wellbeing is monitored with weights recorded using chair scales. Blank record sheets are available to record appointments at services such as the optician and chiropodist, both of whom visit the home. Visitors considered their relatives were well cared for with health matters addressed, often in consultation with families where appropriate. Mention was made of visits from the District Nursing service. Throughout the inspection, it was evident that staff on duty had the greatest respect for residents at Cedardale. All residents and relatives spoken with confirmed this. One relative said that the manager would not tolerate staff who didn’t treat residents with care and courtesy. Systems are in place to offer residents privacy, including in shared rooms, use of the toilet and communicating with visitors. Cedardale aims to provide a home for life, using the expertise and experience of the manager, the support of local health professionals and skills of staff. It is recognised that the home cannot meet needs such as heavy nursing care. Residents’ last wishes are wherever possible identified and recorded. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 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 standard(s) 12,13,14 & 15 Residents have provision to follow their preferred lifestyle which includes social, recreational and spiritual opportunities. EVIDENCE: The statement of purpose gives very clear detail of the style of living provided at Cedardale. Activities suitable for the residents accommodated are provided and specific interests are as far as possible catered for. One resident was being assisted on a one to one basis to make a birthday card and a fan. Another resident showed her crocheting with pride. A resident said sometimes a few of them would go out in the car for ‘little run’. Entertainment is brought to the home. Residents are free to choose whether to engage in an activity. Many said they like to sit in the garden. One is an avid crossword fan and looks forward to her daily paper. A church communion service is held fortnightly in the small lounge. A selection of books is available. One resident played the piano and is considering whether to play for the regular residents sing-a longs. The seating in the lounge is arranged so residents can choose whether to watch the TV. Throughout the inspection, visitors came in and out. Those spoken with said they felt very welcome and were always offered a drink. One family said they had stayed for lunch. Another family said they felt reassured that mother was safe as they were always promptly notified of any incidents or concerns. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 14 Residents are viewed as the key decision maker in their care within a residential setting. Whilst encouragement is given to follow some routines such as day/night separation, individual wishes would be met. A number of residents liked the security of having a structured day and the opportunity to meet with their friends at the meal table. Those who preferred to eat more privately had the option to do so. Provision is made for residents who prefer to ‘dip in and out’ at meal times. Residents can choose their bath days and times. Two waking night staff meet the needs of those who are more wakeful at night. Dress is the choice of the residents, one resident said how she valued ‘looking good’, staff commented that she liked to have colour coordinated clothes. A cook, who has been at the home for many years and knows the residents preferences very well, does the majority of catering. She prides herself on providing good, wholesome food ensuring it is presented attractively. The dining room was set with tablecloths, side plates, cake stand and tumblers. Special diets are met. Whilst there is no recorded specific choice of main meal, in practice residents often choose alternatives. Fish, omelette or salad is always available. One resident said how good the food was, she was not a fan of ‘fiddly tarted up’ food and liked the basic but good home cooking. Residents were offered a glass of sherry or soft drink before lunch as it the custom at Cedardale. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 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 standard(s) 16 & 18 Any concerns about the service are dealt with promptly through proper channels. EVIDENCE: In answer to the inspectors query whether residents or relatives (or in fact staff) could voice any concerns, there was a unanimous response referring to the accessibility, approachability and genuineness of the manager. All felt completely relaxed and confident in talking over any issues with him. One relative spoke of a raising a minor concern and how well it had been dealt with. As the manager believed this was just part of the way in which a responsive service should be run, it had not been recorded in the complaint record. He now recognises such a record would be a valuable part of a quality assurance system. Each room has a copy of the formal complaint procedure, as does the statement of purpose. Both give contact detail of relevant parties with timescales. Residents are protected from the risks of abuse by staff understanding of adult protection and POVA (Protection of Vulnerable Adults) procedures, with copies available of relevant publications. A senior carer is booked to undertake a training the trainer adult protection course. Where there have been any concerns regarding staff integrity, action has been taken. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25 & 26 Residents have a homely and well maintained environment in which to live. EVIDENCE: Cedardale started life as a large family home and was later extended to provide more specialist accommodation. The house retains its origins as a homely environment and fits well into the local area. Furnishings are domestic, suitable for the residents accommodated and well maintained. Currently there is no shaft lift, access to the upper floors is by stair lift. MGL, the owners, recognise the changing and increased needs of people moving into care and are in the initial stages of looking to further extend and rearrange the home. This would reduce the number of shared rooms, provide a new kitchen and laundry, shaft lift and more en suite rooms. Residents using the upper floors are risk assessed as safe independently or needing staff assistance. A family said they had requested their relative move to a ground floor room and this was done. The manager is very conscious of residents’ safety and has arranged for railings to be fitted by the front door and to the rear ramped access. There is wheelchair access to the side of the house. The large rear Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 17 garden is a secure area where residents can wander freely. The lounge leads onto a patio area with seating. Indoors there is a good-sized L shaped lounge, a smaller quiet lounge and a dining room. Currently there is no separate office space, with the hallway being used as a semi office facility. The majority of bedrooms have a good outlook and have good natural light. There is a domestic style kitchen which at the time of inspection was clean and well ordered, and a laundry with domestic washer and drier. Both have facilities to reduce the risks of cross infection. Washing needs are reduced as the majority of sheets and pillowcases are sent to a local laundry. There is a clinical waste contact for the safe disposal of contaminated waste. A cleaner is employed. A number of rooms are en suite, in addition there are separate toilets for general use and a staff toilet. There are two bathrooms, a standard bath on the upper floor and a Parker bath on the ground floor. One room has an en suite shower. Residents have use of a staff call system. A mobile hoist has been purchased which is under a maintenance contract. The manager will access specialist advice regarding suitability of the environment before starting the refurbishment. Residents can chose what items they would like in their rooms, a number had photographs of loved ones. One had brought in her own specialist bed and chair. Residents can choose whether to hold key to their room. Residents said the home was suitably warm in winter. Radiators are fitted with covers to prevent risk of burns. The temperature of hot water accessible to residents is regulated by pre set valves. The fire safety risk assessment could not be located. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 & 30 Staff are well liked, provide good care and uphold clients rights. Protection of residents would better evidenced by sound recruitment practices and staff training as planned. EVIDENCE: Residents and relatives felt there were sufficient staff on duty to provide good care. Staffing levels have been increased following the change of registration. One relative thought that there were times when residents presented challenges but recognised it was not feasible to provide one to one care just to cover such eventualities. Domestic staff are appointed which relieves care staff to work primarily with residents. Throughout the inspection there was evidence of very good staff/ resident interactions. All spoke well of staff commenting that they listened, got to know individuals and were approachable. Staff balance personal care needs with time for one to one chats, activities and recording daily events. A senior carer said that the manager recognised the time taken to carry out necessary paperwork. Staff referred to being provided with training, a more recently recruited member of staff spoke of attending 6 courses and plans to start NVQ level 2 in Care. Other staff had achieved or were working towards this qualification, a senior then plans to do level 3. A training matrix is held which is to be updated. Staff said there was greater emphasis on providing training, including training in dementia awareness. Further training is planned to ensure that all staff are similarly trained. Two people are undertaking TOPPS induction. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 19 Whilst there are no concerns as to the skills and integrity of the current staff team, recruitment does not support good practice to protect residents. The implementation of a sound recruitment process which includes satisfactory references being received before employment commences, a recorded induction for all staff, a structured and recorded interview, validated checks on employment history and a record of the organisation/company providing the employment reference would provide residents with increased safety. There must also be a record of the dates staff begin and finish employ at Cedardale. The owners are in the process of providing staff with a statement of terms and conditions. A member of staff confirmed she had filled out an application form (which includes a full rehabilitation of offenders declaration), attended for interview and had worked alongside a more experienced member of staff until she got to know residents. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36,37 & 38 Residents live in a well managed service where safety would be enhanced by more thorough fire safety practices. EVIDENCE: The manager has many years experience in the care and nursing field, for a number of years running another home for older people with dementia. All spoken with said he was very easy to talk to, would not tolerate poor standards and had the wellbeing of residents at heart. He was regularly in the home and had a very good knowledge of individual residents. He was responsive to recommendations made as part of the inspection. To support the manager there are senior staff, with one taking a lead role deputising for the manager. Staff said there would always be a senior on duty. It would be helpful to have that person, and the roles of all staff, recorded on the staff roster. Staff referred to staff meetings being held and having handovers Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 21 between shifts. Certain staff have delegated responsibilities such as health and safety. Residents meetings have been held. A quality assurance system is progressing and will include formalising feedback from families and professionals. Relatives said they could air their views with the manager or a senior. The owners are willing to invest in existing and future service provision, such as the new extension. There is current employers liability and general insurance. Recognising that residents need access to cash for items such as hairdressing and shopping, the home will hold money for safekeeping. There is no other involvement in residents’ monies. Money for safekeeping is held individually with an associated record. Verification of receipt and expenditure would be enhanced by improved record keeping linking receipt and expenditure to receipts and regular audits of the record. The record and money balanced on those checked during the inspection. A small float provided by the owners is available for use in delay in receiving funds for a resident. The manager currently supervises staff, time limitations have restricted the frequency of supervisions. A senior is to be trained in supervision skills and will share the role. Staff are required to read policies relating to the service as part of their induction. Staff have worked hard to set up records as required by regulation for the protection of residents. Staff and resident photographs have been taken and the majority are in place. A record of food is held. To monitor nutrition to those at risk, alternatives should be recorded in detail. Staff personnel files must evidence sound recruitment practice and as identified previously, must contain required documentation. Activities are now recorded in individual care plans. An accident book and incident record are held. The system of storing completed accident forms does not allow for ease of tracking hazards. A member of staff has recently taken over the role of health and safety coordinator and is setting up monitoring systems. A priority need is to set up fire drills for staff and call point testing to promote safety in the event of fire. Not all staff have on record recent attendance at a fire drill. Call points are not tested in a sequence which ensures each is regularly tested. Emergency lights are tested regularly. Service and supply certificates were in date and in good order. Fridge and freezer temperatures were recorded daily. In the interests of safety, all residents using a wheelchair are required to use footplates. Prevention of falls from a height is promoted by the use of window restrictors. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 4 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 3 2 2 2 1 Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? 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 19.5 Regulation 23 (4) (c) Requirement As required by Fire Safety Regulations 1992 (as amended) a fire risk assessment must be carried out and updated as necessary. No member of staff shall be employed to work at the home unless a minimum of two satisfactory written references have been obtained, their employment history, including the reason for leaving any employ with vulnerable people, has been obtained and validated. Part of this requirement is carried forward from a previous inspection. There must be evidence that all staff have the training necessary to carry out the work they are to perform, this will include evidence that all staff have · a recorded induction procedure · training in Basic Food hygiene/food hygiene awareness where the member of staff prepares, handles or stores food. · training which includes Timescale for action To be available by 31 August 2005 and updated thereafter To be actioned in respect of all recruitmen t from 20 July 2005 thereafter 2. 29 19 (1) 3. 30 18 (1) (c) Action plan to be received by 31 August 2005 Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 24 4. 35 19 (1) caring for older people with dementia · updated moving and handling training Part of this requirement has been carried forward from two previous inspections. There must be a record of the dates staff employment commences and finishes. 5. 38 23 (4) (d) 6. 38 23 (4) (c) To be actioned by 31 July 2005 and thereafter All staff must attend fire drills at To be intervals as recommended by the actioned by Fire Safety Officer, this will be at 31 July not greater than 3 monthly 2005 and intervals for night staff and not thereafter greater than 6 monthly intervals for day staff. There must be recorded evidence that this training has been undertaken. To monitor that fire safety To be equipment is working properly, actioned fire call points must be tested from 20 regularly. Using a sequence July 2005 which ensures each point is and tested regularly may ensure this thereafter is carried out properly. 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 2.2 Good Practice Recommendations Consideration should be given to reviewing the contract to include the room to be occupied, more detail of residents’ rights, greater detail of what the fee includes and to adjust the complaint statement – this is repeated from a previous inspection. Work on further developing the care plans should be carried out to ensure consistent specific detail of care and support is available to staff. Risk assessments, or evidence that a risk assessment has been carried out, should be available in response to H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 25 2. 3. 7.2 7.2 Cedardale Residential Home 4. 5. 27.2 29.1 6. 7. 8. 9. 10. 11. 12. 29.2 29.5 35.1 35.2 36.2 37.1 38.3 incidents recorded in the daily record sheets. To identify the role of staff on duty and the senior on shift, the roster should record job titles. A structured and recorded interview should be carried out where employment history is verified and the applicants skills, knowledge, attitude and training are confirmed – this is repeated from a previous inspection. The reference should ensure full detail of the referee, including the name of the company/organisation providing the reference, is recorded. As planned, all staff should have a statement of terms and conditions of employment. The records and associated money held for safekeeping should be regularly audited by a third party. The record of monies held for safekeeping should link income and expenditure to a receipt. Care staff should receive formal recorded supervision not less than 6 times a year. The record of food should include detail of any alternatives provided - this is repeated from a previous inspection. Systems should be put in place to track patterns of accidents so that risks can be identified and as far as possible removed. Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Cedardale Residential Home H56-H06 S59264 Cedardale V230148 190705 Stage 4.doc Version 1.30 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. 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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