Inspection on 10/05/07 for Silverleigh Cedars

This inspection was carried out on 10th May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Silverleigh Cedars 30/06/09

Silverleigh Cedars 24/01/06

Silverleigh Cedars 03/08/05

Silverleigh Cedars 25/01/05

Silverleigh Cedars 03/08/04

Silverleigh Cedars 17/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Silverleigh Cedars Silver Street Axminster Devon EX13 5AF Lead Inspector Sue Dewis Unannounced Inspection 10th May 2007 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 Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Silverleigh Cedars Address Silver Street Axminster Devon EX13 5AF 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) 01297 32611 01297 32559 Silverleigh Limited Christine Susan Brooke Care Home 54 Category(ies) of Dementia - over 65 years of age (54), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (54), Old age, not falling within any other category (54), Physical disability over 65 years of age (54) Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One person under the age of 65 years may be admitted to the home. Date of last inspection 24th January 2006 Brief Description of the Service: Silverleigh Cedars is a large, detached, converted and extended property set in its own grounds in the centre of the town of Axminster. The home is laid out in two separate areas - one side is known as Silverleigh and the other side is known as Cedars. Accommodation and personal care is provided for up to 54 older people who may also have a physical disability, mental disorder or a dementia type illness. There are five lounges and two dining rooms plus other smaller sitting areas around the home. There are 36 single bedrooms, 5 double rooms and 4 apartments each consisting of an entrance hall, living room, kitchenette, bedroom and bathroom. 30 of the bedrooms have an en suite W.C. There are bedrooms on the ground, first and second floors. Passenger lifts provide access to all levels. There is also a stair lift. Outside, there are pleasant and interesting gardens with plenty of seating, and a private parking area. Fees for the home are £733.00 each week and include activity sessions, outings and one monthly hair appointment. They do not include personal toiletries, newspapers or transport to appointments. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk A copy of the inspection report for the home is available in a folder in the main reception area. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 10 and a half hours, one day at the beginning of May 2007. The home had been notified that an inspection would take place within three months and had returned a pre-inspection questionnaire, information from which was used to write this report. During the inspection the care of 3 residents was looked at closely. This involved the inspector looking at the residents’ individual plans of care, and speaking with the resident and staff who care for them. This enables the Commission to better understand the experience of residents living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. As part of this, questionnaires were sent out to 27 residents, 1 GP surgery, 27 relatives and 22 staff. At the time of writing the report, responses had been received from 24 residents, 7 GP’s, 14 relatives and 15 staff. During the inspection the inspector spoke with 3 residents individually and four in a group setting. A considerable amount of time was also spent in one of the lounges observing the interaction between staff and residents. The inspector also spoke with 4 staff and the manager and the owner. A tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files. What the service does well: People are only admitted to the home when the home has assured them that their needs can be met. Once in the home a comprehensive care plan is completed with them to ensure staff are aware of how their needs are to be met. Health care professionals are involved as needed and medication is stored securely and administered in a safe manner. Staff are well trained in all aspects of care and the high staffing levels ensure that the personal care needs of people who live at the home are well met. Activities, entertainments and outings are excellent and people are provided with a high level of individual support to ensure their needs can be met. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 6 Meals are nutritious and there is always a choice available. People who live at the home are protected, by the home’s recruitment practices and by staff who have received appropriate training. The environment is excellent, it is comfortable, well maintained, clean and homely. There are many aids and adaptations around the home to ensure everyone can move freely around the home. The manager keeps up to date with new information from the Commission and is working on a new quality assurance scheme that will involve everyone concerned with the home. Comments on cards received from people who live in, visit and work at the home included ‘I am very happy with the care and attention my mother receives in Silverleigh. It is well looked after in every way and so is she’, ‘It maintains an individual’s independence and provides an excellent choice of activities’, ‘I think the care provided by Silverleigh is excellent and difficult to criticise’ and ‘Staff ratio good, good routine and plenty of activities’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough assessment of the support people require ensures that the home can appropriately meet their care needs. The home does not provide intermediate care. EVIDENCE: Three people’s files were looked at and all contained copies of their contracts which included information on updates of fees. Copies of contracts are also given to the person’s representative. The manager is aware of the Office of Fair Trading website and ensures the contracts for the home are in line with this guidance. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 9 Wherever possible someone (usually the Manager) from the home visits the prospective resident to carry out an assessment of their needs. The assessment covers all relevant aspects of their personal and health and social care needs. The prospective resident is also invited to visit the home, stay for a meal, or to have day care. They may also be offered a short stay at the home before making a decision to move in permanently. People who were spoken with said that they felt they had made the right decision in moving into the home, and that all their needs were well met. As well as verbal information, prospective residents also receive a comprehensive ‘welcome pack’ containing a range of useful information about the home. A copy of this, plus the most recent inspection report, is kept in the entrance hallway. The three files that were looked at contained detailed pre-admission assessments. The home also writes to each prospective resident to confirm that their assessed needs can be met. The home does not provide intermediate care. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are well formulated and give clear information to enable staff to meet people’s health and social care needs. Personal and health care needs are well met in an individual manner by caring and informed staff and people are treated with dignity and respect. To ensure people’s safety, all medicines are stored securely and administered appropriately. EVIDENCE: Each care plan is divided into two parts – one part covers the health and personal care needs of each person and the other part covers their daily life Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 11 and social care needs. The care staff have responsibility for completing and reviewing the health and personal care plans. Staff said that they found the care plans very useful and had been involved in drawing them up. There was also evidence on the care plans that the people who live at the home and their representatives had been involved in the process. Daily reports showed evidence of how the plans had been put into action and the person’s needs met. Staff were able to describe the varying care needs of people who live at the home and how these are met on a daily basis. People who live at the home were very complimentary about the staff and the way their needs are met. They said that they were always treated with respect and their personal needs attended to in private and in a discreet manner. Comments on cards received included ‘I am very happy to be in this home. I have always found the staff very helpful and friendly’ and ‘Couldn’t have better care’. However, one or two cards indicated that it sometimes took a while for call bells to be answered and that staff were often very busy. The manager and owner subsequently stated that they felt this was not the case and ‘that given the high levels of care staff, well in excess of the requirement, it would be illogical and very unlikely that call bells were not answered promptly’. The plans showed where health care needs had been identified and action taken to ensure the needs were met, for example, involving the GP or District Nurse. Comments received from GP’s who visit the home included ‘First class service’, ‘Excellent home (all respects)’ and ‘I couldn’t think of anywhere better’. The Activities Organisers have responsibility for the social activity care plans which are also detailed and show what activities the person likes and has taken part in. There are two separate storage areas for medications, one in Silverleigh and one in Cedars. The medicines are stored in modern, well-equipped and secure rooms. Each separate area has a medicines trolley and locked medicines cupboards. Tablets are supplied where possible in a monitored dosage system (MDS). Good records are kept showing medicines ordered and administered, and also where unwanted medicines have been returned to the pharmacist. Policies on the safe administration of medicines are in. All staff who give out medicines have undertaken training on the safe administration of medicines. There is a clear procedure for any resident who asks for or needs extra prescribed medicine or non prescribed medicines, to ensure that the correct dosage is administered. No residents hold or administer their own medicines at the time of this inspection, and we discussed ways of enabling more residents to be responsible for their own medicines. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Links with visitors and the community are excellent, giving opportunities to support and enrich people’s social life. An excellent range of activities and entertainments are on offer in order to ensure people are stimulated and occupied. Meals were seen to be well presented, providing people with nutritious variety and choice EVIDENCE: Separate care plans have been drawn up covering the social needs of all of the people who live at the home. The home employs an activities organiser and large team of activities staff to ensure all individual needs are met. There are now six activity staff on each day Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 13 The interaction between several residents and their surroundings was closely observed for an hour during the morning. There was initially lots of activity including the ‘Silverleigh Shoppe’ (where people can purchase items at cost price). Several people then wandered off for a game of scrabble or for a walk into town. Although the general activity declined, care staff kept popping into the lounge to ensure people were OK and didn’t need anything. Several residents took advantage of the quieter time to take a nap or watch the TV. Throughout the observation there were activity staff talking quietly to people who live at the home on a one to one basis. Some of the people who live at the home have a high level of dementia, staff were careful to include them in all interactions. In the afternoon, three teams of people who live at the home and staff took part in a quiz, when there was much laughter and participation even by those people not in the teams. People who live at the home spoke about some of the things they enjoy doing including knitting, crosswords and reading. Exercise classes, swimming sessions, concerts and scrabble are just some of the activities that are provided. There are also regular daily bus outings and people who live at the home spoke about how much they enjoyed these. On the day of the inspection there was to be a trip to a music concert being held in the town, but bad weather prevented this. One person who lived at the home said that there was ‘lots to do if you want to, can go out on the mini bus’. Visitors were seen around the home throughout the inspection. Many positive comments were received from relatives via the comment cards and included, ‘I am encouraged to spend several hours with my husband and join him at meal times’, ‘Her family is kept well informed and consulted at all times’, and ‘It maintains an individual’s independence and provides an excellent choice of activities’. People who live at the home spoke about the choices they are able to make throughout the day, which includes where and how they spend their time, what they have to eat and when they go to bed. Regular meetings are held to enable the people who live at the home express their views. People also spoke about how much they enjoyed the food and said that they were able to have something else if they did not like the main course. Comments on cards received from people who live at the home included ‘On the occasions when I need something different to the menu the cook is willing to give me an alternative.’ Sample menus that were provided prior to the inspection showed a variety of balanced nutritional meals. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live, visit and work at the home feel that any complaints would be dealt with appropriately. People are protected by staff that are able to recognise abuse and know their duty to report poor practice. EVIDENCE: The home has a clearly worded complaints procedure, a copy of which is provided in the ‘welcome pack’ and a copy is kept in the entrance hallway. Several people who live at the home said they felt confident that if they had any concerns or complaints they could speak to one of the staff or to the manager and the matter would be sorted out quickly and satisfactorily. However, comments were received on a card from one person who lived at the home that they would like to know who to talk to when they were unhappy. The manager and owner were very concerned about this and will be looking at ways to ensure everyone who lives at the home knows who to talk with if they are unhappy. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 15 Staff who were spoken with confirmed that they had received training on the protection of vulnerable adults (POVA). They were aware of the home’s policies and procedures, and also knew about the Devon Social Services Alerters’ Guidance. The staff were able to describe varying types of abuse and were clear about the procedure for raising any concerns they might have, including contacting outside agencies if necessary. They were confident that they could speak out if they had any concerns and that these would be dealt with appropriately. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live at the home do so in a clean, safe, comfortable and homely environment that has been adapted to meet their needs. EVIDENCE: A tour of the building was made including the communal areas and of some of the bedrooms. There are several communal spaces, including some quiet areas, where people can sit away from the general bustle of the home. All areas of the home are maintained to a very high standard, with several maintenance people employed to ensure that all areas are regularly decorated and repairs carried out promptly. The gardens and exterior of the home were Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 17 neat and tidy and in good order. People who live at the home said that they enjoyed being able to sit in the gardens when the weather is fine. There is easy access into and out of the home. Some bedroom doors have been fitted with push button door openers, to allow those people who use wheelchairs independent access to and from their bedrooms. There is a range of aids and adaptations to help staff to help people who live at the home to be as independent as possible. These include ramps, grab rails and bath hoists. The individual bedrooms of people who live at the home are personalised and reflect the personality of the occupant. Those rooms that have shared occupancy have screening fitted to maintain the privacy of those who share the room. The home was very clean and tidy throughout. Staff confirmed that they had received some training on the control of infection and that there were specific procedures to be followed if caring for residents with MRSA. Disposable gloves and aprons were available in individual bedrooms and other areas around the home. Comments received on cards from visitors included ‘Excellent maintenance of fabric of building, grounds and decorations’ and ‘Silverleigh is an extremely pleasant place to visit being airy and bright, always clean and well maintained’. Cards received from people who live at the home included comments such as ‘Everything is clean and fresh’. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. High staffing levels and a full training programme ensure that the needs of people who live at the home are well met. The procedures for the recruitment of staff are entirely robust and offer full protection to people who live at the home. EVIDENCE: Copies of staff rotas were supplied prior to this inspection. Staff spoken with during the inspection confirmed that there have been no changes in the staffing levels since the last inspection. People who live in the home said they were satisfied with the number of staff provided, their caring manner, and their competence. One commented that there was ‘always plenty of staff about in case you need anything.’ During the inspection staff were seen to be very prompt in answering call bells and requests for assistance. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 19 However, two comment cards received from people who live at the home indicated that they felt sometimes staff were too busy to answer their call bells, please also see page 12. The recruitment files of three staff were looked at including that of the person most recently employed These showed that application forms had been completed, interviews carried out, at least two satisfactory references plus CRB (police checks) and POVA (Protection Of Vulnerable Adults) checks carried out. Job descriptions, contracts of employment, staff evaluation and induction records were all in place. Staff talked about the training they have received and said they felt the level of training was very good. Information provided for this inspection shows that staff have received a wide range of training both in-house and through external training providers. All mandatory health and safety topics have been covered plus specific care related topics such as ‘old age’, stroke awareness, pain relief, aggression, safe administration of medicines and the protection of vulnerable adults. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed, resulting in practices that seek the opinions of everyone involved with the home and promote and safeguard their health, safety and welfare. EVIDENCE: The registered manager of Silverleigh Cedars has worked in the care sector for many years and is a Registered Nurse. Throughout the inspection she demonstrated a detailed knowledge of the people who live and work at the home and all aspects of the service provided. Those who live and work at the Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 21 home expressed confidence in the management processes of the home. Staff said that they felt encouraged to do a good job and that they are always given praise and feedback about their work. As well as the general enquiries made by staff, to ensure residents’ needs are met, the home also conducts a formal quality assurance process. Everyone involved with Silverleigh Cedars is asked for their opinions on the service provided by the home. The method determining the quality of care provided is changing and the manager is looking to involve staff and visitors more. The manager is aware of the new AQAA (Annual Quality Assurance Assessment) system that we have introduced, and is planning on using this to help assess the quality of care at the home. A newsletter is now being sent to people involved with the home to keep them up to date with what is going on. There are regular meetings for all who live at the home and a quality assurance survey has recently been sent out. The home is hoping to shortly achieve the IIP (Investors In People) award. The inspector was told that all people who live at the home (or their representatives) manage their own personal allowances. The pre-inspection questionnaire provided evidence that Silverleigh Cedars complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. However, the fire alarm is not tested at the same time on the same day so everyone is not always aware that the sounding of the alarm is only a test. Also there is very little detail recorded of exactly what the training staff receive covers. So that the risk of burning from hot surfaces is minimised, all radiators within the home are due to be covered. An individual risk assessment has been completed on those not yet covered. All windows above ground floor level are fitted with restrictors, in order to minimise the risk of any resident falling from these windows. Staff said that they had received training in health and safety and were able to describe safe systems of working and were aware of their own responsibilities. Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X 4 X 3 X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X N/A X X 3 Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Silverleigh Cedars DS0000022030.V334778.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!