Inspection on 02/11/06 for The Cedars

This inspection was carried out on 2nd November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Cedars 12/12/05

The Cedars 15/06/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 The Cedars 2 Harding Road Hanley Stoke on Trent Staffordshire ST1 3BQ Lead Inspector Jane Capron Key Unannounced Inspection 2 November 2006 09:30 The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 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 The Cedars DS0000064029.V317856.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 Adults 18-65. 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. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars Address 2 Harding Road Hanley Stoke on Trent Staffordshire ST1 3BQ 01782 269739 01782 269187 chris@delamcare.co.uk 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) Delam Care Ltd Miss Tracy Anne Baddeley Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12 December 2005 Brief Description of the Service: The Cedars is a long-term care home for six people with a learning disability and/ or mental ill health. Some residents have both conditions. It is run by Delam Care, a company owned by Caretech. The property is a detached Victorian property in Hanley that is adjacent to two other care homes owned by the same company. The Care Manager is also responsible for the two adjoining homes. The home has a small back yard area and a small front garden and shares a laundry with the two adjacent care homes. The home has six single bedrooms, four upstairs and two on the ground floor. Residents have the opportunity to attend college and the support staff arrange some activities within the home. Residents have the opportunity to go on holiday at their own cost. The home is able to provide care for service users whose main needs are for support, encouragement and general supervision. The staffing levels allow for one staff member to be on duty at all times and for one staff to sleep at the home. The home monitors, supports and encourages the residents to access appropriate health care facilities and to maintain their own personal care. Residents are involved a range of domestic and household tasks within the home. The current fees range from £294 to £345 per week. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on one day over a six-hour period. Discussions were held with five of the six residents. The sixth resident was staying with his family. Discussions were also held with the Care Manager and with the house leader who was the one staff member on duty. The inspection looked at the arrangements for meeting residents’ health and personal care needs, their access to the community and the opportunities to take part in social and leisure activities. In addition the arrangements for safeguarding residents was looked at including managing their money and the arrangements for responding to complaints. The communal areas where looked at as well as a sample of residents’ bedrooms. Prior to the inspection a survey of the residents took place to gather their views over the care provided at the home. What the service does well: The residents had all lived at the home for a number of years and were quite happy with the care provided. Comments from residents about the home included: ‘I like living here’, ‘ We all get on well’, ‘We have resident meetings where we talk about what we want to do’ and ‘ I like my bedroom’. Residents liked their bedrooms and they provided them with privacy. All bedrooms were satisfactorily decorated and were personalised with photos, pictures and ornaments. Residents felt that staff were quite supportive and that they got on satisfactorily with them. Residents participated in aspects of running the home. They planned the menus, helped with keeping their bedrooms clean and tidy, and helped with some meal preparation and with laying and clearing the table. Residents made choices over their lives. They had chosen whether to go to college or not. They could access their bedrooms or the communal rooms at anytime. Most residents went shopping regularly and several went out for lunch once a week. All the residents had been on holiday to Blackpool. The home had support plans in place that outlined the needs of the residents and how they were to be met. The home was in the process of developing person centred plans. Risk assessments had been developed with plans in place to prevent unacceptable risks to residents whilst not placing them under unnecessary restrictions. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 6 The home was meeting the health and personal care needs of the residents. Residents attended the GP, the dentist, the optician and the chiropodist. The residents received psychiatric and psychological services and their mental health was monitored and reviewed. The Care Manager has been in post for some time and had the necessary skill, knowledge and experience to effectively manage the home. She had obtained the qualification required to manage a care home. What has improved since the last inspection? What they could do better: Whilst the home was meeting most of the requirements and standards there were some areas that needed to be addressed to improve the service. The home needed to make sure that a protocol was in place for medication that was used as required to make sure that all staff were aware when this medication should be given. It was also recommended that staff had more indepth training in medication. The home was generally clean and tidy but the home needed to make sure that high areas were always kept clean. In addition there was no hot water in the basin in the upstairs toilet. At the time of the inspection the home had no staff qualified to NVQ level 2. Although one staff member had started the qualification the home needs to work to increase the number of staff qualified. The home had procedures in place for fire safety but needed to ensure that the fire door propped open had appropriate door closures fitted. A number of recommendation were made that would provide the residents with a better service. Whilst residents took part in reviews about their care no other significant people, like doctors and nurses and relatives if appropriate were involved in this. It was also recommended that residents could take a bigger part in running the home. For example residents could help in recruiting new staff. Residents’ lives could be improved if there was more encouragement and support for The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 7 residents to take part in more fulfilling and social activities both in the home and in the community. Whilst the home had a complaints procedure residents may understand this better if it was in easier language or in a picture format. 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. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the home had no admissions it is the home’s policy to undertake an assessment of prospective residents to identify whether the home can meet their needs. Residents are made aware of their rights and responsibilities through the provision of a contract. EVIDENCE: The home had had no residents admitted to the home for a number of years with all the residents having lived at the home for a long time. However it was the home’s policy to undertake an assessment of all prospective residents and this has been demonstrated at the two adjoining home where admissions have taken place. The home did however complete resident assessments to ensure that the home was aware of their needs and that residents’ support plans were up to date. Residents were aware of their rights and responsibilities having been provided with a contract both by the local authority and by the home. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has support plans in place that identify the needs of residents and although reviewed with the resident this process did not always include any significant others. The home has developed risk assessments to ensure that residents were not subject to unnecessary restrictions or exposed to unnecessary risks. Residents are supported to make decisions and opportunities are provided for residents to participate in some aspects of running the home although there was scope for this area to be developed. EVIDENCE: A sample of support plans was seen. These showed that the needs of residents had been identified including general and mental health, personal care, financial support, domestic activities and social and leisure needs. The plans identified an activity schedule for each resident. The support plans showed the needs of residents and the actions needed to meet these needs. Files showed The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 11 that residents took part in internal evaluations of the elements of the support plans. Those under care co-ordination were being reviewed. However there were no reviews with significant others on file for other residents. Residents had key workers and residents met with them on a monthly basis. Residents spoken to said they discussed their needs and how they were doing with staff. Staff were in the process of developing person centred plans but there was some way to go and no planning meetings had yet been held. The home had developed individual risk assessments covering such areas as the use of domestic appliances, bathing, the use of hot water and community access. Records showed that these were being reviewed. Residents said that they decided on how they spent their time. They chose whether to go to college or not, the time they got up and went to bed, whether they took part in activities and where to spend their time either in their bedrooms or in the communal rooms. Staff provided support to residents in for example deciding on menus and in shopping. Residents had took part in aspects of running the home including doing the food shopping, planning the menus and helping in food preparation and laying and clearing the table, doing the washing and keeping their bedrooms clean and tidy. The home had resident meetings approximately monthly. There was scope for the residents to be more involved in aspects of running the home. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides opportunities for residents to take part in educational and leisure activities in and out of the home but the level of staffing limits the amount of time residents can be supported. Residents are able to maintain and develop relationships with family and friends. The home provides meals based on residents’ choices. EVIDENCE: All the residents had the option to attend college courses but only one had taken up the opportunity. One resident spent a lot of the week attending groups and another attended a group once a week for people with mental health difficulties. The other residents had chosen to remain at the home but did quite regularly go out of the home to go for example shopping. All the residents accessed the community for example going shopping for personal items, for food shopping and more regularly to buy milk and bread for the The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 13 home and to the bank. The residents used local health resources. One resident went to the local pub regularly and three residents always went out for lunch once a week. The home organised occasional trips to the theatre, to a disco, and trips out. Recently they had been to Donnington and Blackpool. Residents had been on holiday earlier in the year. All the residents had difficulties in self-motivation and needed staff encouragement to take part in activities. Due to the staffing levels the amount of time able to encourage and support residents was limited. However most residents were able to access the community independently or with another resident. The home provided a schedule of activities that although often residents were not motivated to take part. There was evidence that the home had provided activities including baking, beauty evening, games, darts and word searches. The home had TV, video and DVD in lounge and residents have TVs in their bedrooms. The home’s routines were quite flexible for example times for getting up and going to bed, and residents can spent time in their bedrooms or communal rooms when they wanted to. Bedrooms were lockable and provided residents with privacy. The staff member on duty had regular interactions with residents and residents were at ease with him. Residents are expected to help out with domestic tasks. All residents were registered to vote. Residents were encouraged to maintain and develop relationships with family and friends. Several residents said that they had friends in the home. Several residents had regular contact with family members seeing them several times a week. Residents generally said they liked the food. Comments included ‘ I like the meals’, ‘I help with the cooking’, ‘the food is OK. I’ve no complaints’ and ‘If you don’t like something you can have something else’. All residents said the home had weekly meetings to put together the menu. Breakfast was taken whenever residents got up and was a choice of cereals and toast. Lunch tended to be a light meal such as sandwiches, soup, or something on toast. There was no sweet on the menu but there was always fruit available. On the day of the inspection the fruit bowl contained apples, oranges and pears. The main meal was at teatime and consisted of a main meal and sweet. The home provided a supper. Residents said that they had sufficient food. The home was not providing for any special diets and no resident needed support to eat their meals. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was meeting the healthcare and personal care needs of the residents. The medication needs of the residents was being met but the home needed to ensure that a protocol for PRN medication was always in place. EVIDENCE: The home’s support plans identified the personal care and general and mental health care needs of residents. Records confirmed that residents received health services to meet their needs. Residents stated that they saw the GP, the optician, dentist and chiropodists. Several received psychiatric and mental health services and residents had psychologist involvement when appropriate. Residents attend for smear tests where applicable Medical contacts were recorded in the records. Discussions with staff confirmed that residents’ mental health was monitored and action taken if needed and reviews were taking place. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 15 The records showed that residents’ personal care needs were addressed. Residents confirmed they had baths or showers daily and that staff encouraged them to meet their own personal care needs. Residents were encouraged to dress appropriately and to look after their hair and nails. Residents weight was checked monthly. The home had a key worker system in place. The arrangements for administrating medication were checked. The home had a medication procedure in place. The home stored medication in a locked cabinet in the office. The home operated a monitored dosage system. A sample of medication and records was checked and this showed that the medication as outlined on the records was being administered and there were no gaps in the medication administration records. All staff have had some training in the administration in medication. Two residents self medicated. Checks with one confirmed she was aware of when to take medicating and the arrangements for this was inspected. The two residents kept their medication securely locked in their bedroom. They were both aware of when and how to take their medication and said that staff checked whether they had taken their medication. The home had undertaken assessments to identify whether these residents were able to take their medication safely. These had been reviewed. The home had no controlled medication. Several residents had some PRN medication and in not all instances was there a protocol in place. All staff had received some training in medication but it would be beneficial if this was in greater depth. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were aware of how to complain and felt that staff would address issues they raised. However it would be of benefit to the residents for the procedure to be in a more user-friendly format. The procedures for adult protection and for managing residents’ finances enabled the residents to feel safe in the home. EVIDENCE: The home had a complaints procedure that was displayed in the entrance hall. It would benefit the residents if this was in a more user friendly format. The home had received one complaint since last inspection and this had been promptly addressed by the home. Residents spoken to were able to describe how they would raise any issues with comments such as ‘I tell the manager if I have a problem’, ‘If I have a problem I tell the staff and they sort it’. Residents spoken to felt that staff would address any problems they raised. Several residents said that if a problem wasn’t sorted they would go to the Care Manager’s manager. The residents also raised issues at the regular resident meetings. The home had procedures in place to protect the residents from abuse. The home provided staff with training in adult protection. Residents spoken to felt safe at the home. The home had procedures in place to safeguard residents’ The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 17 finances. Residents had support plans related to budgeting and all transactions were recorded. Expenditure over a certain amount was supported by receipts. Records were checked on a daily basis. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided residents with satisfactory private and communal accommodation. The bedrooms provided residents with privacy and the opportunity to personalise their rooms to it their own. The home’s cleaning procedures provided residents with a home that was generally clean and hygienic. EVIDENCE: The home was located in an area near Hanley Park and close to other care homes providing care to residents with similar needs owned by the same company. The home was located about a 20- 30 minutes walk from the shopping centre at Hanley. The home had a small rear garden. The home was suitably ventilated and heated. The home had a lounge and separate dining room, which were suitably furnished and decorated in a domestic manner. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 19 There was a domestic style kitchen, which was quite small. The home had a shower room downstairs with toilet and basin. There was a further toilet downstairs. There was a toilet upstairs toilet as well as a bathroom with Jacuzzi bath. The home provided adequate single bedroom accommodation although no rooms had ensuite facilities and some furniture was quite old. The bedrooms were satisfactorily decorated and provided residents with adequate storage space. Bedrooms provided residents with privacy all being lockable. Bedrooms also had a lockable cupboard. Bedrooms were personalised with posters, pictures and ornaments and had TVs. The home was generally clean and tidy and the home had procedures in place to control the spread of infections. There were cobwebs noticed in the upstairs toilet and the flex from the landing light was covered in dust and was dirty. The home had cleaning schedules in place. Aprons and gloves were provided. It was noted that, although run for some time there was no hot water in the basin in the upstairs toilet. The home shared a small laundry with the two adjoining care homes and this was satisfactory to meet the laundry needs of the home. All staff did some infection control training in induction. One staff member had done a distance learning training in infection control. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided staffing levels that were adequate to meet the health and personal care needs of the residents and limited time to support residents to undertake activities and to access the community. The home’s recruitment procedures were safeguarding the residents. Unqualified staff was supporting the residents. EVIDENCE: The home’s staffing levels allowed for one staff member to be on duty at all times. This meant that the home was only able to provide for residents whose needs were in the main for support, encouragement and supervision. The home had some additional support provided by the Care Manager and part time activity staff member that supported this home and two others. The staffing levels enabled residents to be supported to have health and personal care needs met and to have limited support to access community and in house activities. The home has a staffing of three fulltime staff but currently there was one vacancy. The support to fill the vacancy was being provided by the The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 21 current staff working additional hours, the Care Manager and staff from the adjoining homes. These staff knew the residents. Staff had completed induction training and training in health and safety and such areas as adult protection, medication, mental health awareness and noncrisis intervention. The home had no staff qualified to NVQ level 2 at present although one staff member had started the qualification. The home maintained suitable training records. The residents liked the staff member on duty. He had a friendly and relaxed attitude and related positively with residents. He was aware of residents’ needs. Although time was limited he supported residents to undertake activities in the home as well as finding time to spend time with them. A sample of staff personnel files was inspected. These contained application forms, references and confirmation that a police check had been completed. There was evidence of a formal interview process taking place. Files confirmed that checks were being made of staff’s identities. Staff were receiving support to undertake their role with individual supervision and staff meetings being held. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents were benefiting from a manager that had the necessary experience, knowledge and qualifications and was effectively managing the home. The external quality audit of the home and subsequent action plan was improving the standard of care for the residents. However there was scope for the review of the home to more regularly seek the views of residents and to include the views of other relevant people. Generally the home was providing the residents with a safe environment but did need to ensure that door closures were fitted where needed and that the fire risk assessment was completed. EVIDENCE: The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 23 The Care Manager had the necessary knowledge, skill and experience to effectively manage the home. She has completed the relevant qualification for managers of care homes. The manager attended periodic training to ensure her knowledge remained current. Earlier in the year the home had a full quality audit by Care Tech, the company that has bought Delam Care. This covered all the requirements and standards including health and safety and care practices. The staff have recently had a briefing in quality assurance prior to implementing new systems although it is currently unclear what form the new quality assurance system will take. The home developed an improvement plan based on the outcomes from the external audit. Although the home had previously surveyed the residents to ascertain their views on the home this had not been completed for some time. Also their was no evidence of the home seeking the views of relevant others i.e. health care staff and relatives. The home did have regular resident meetings where residents’ views were sought. The home was in the process of implementing Caretech’s health and safety policy and procedures. The manager was in the processing of completing an updated fire risk assessment. The staff had received health and safety training including food safety, health and safety. The two care staff had received fire marshal training. The home was undertaking fire safety checks including the fire alarm weekly and the emergency lighting monthly. The fire safety equipment had been serviced. The home had had four fire drills in 2006. The office door was a fire door but was being propped open and this needed to have an appropriate door closure fitted. The home had undertaken PAT testing. The gas safety and the electrical installation checks were current. The home maintained records of accidents. Checks were being made on the temperature of water both to protect residents from scalding and to control the risk of the legionella bacteria. The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 25 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. 2. 3. 4. 5. 6. Standard YA20 YA30 YA30 YA32 YA42 YA42 Regulation 13(2) 22(2)(d) 23(2)(j) 18(1)(a) 23(4)(c) 23(4)(a) Requirement To ensure a protocol is in place for all PRN medication To ensure that the home is kept clean at all times. To ensure that hot water is always provided in the basin in the upstairs toilet. To increase the number of suitably qualified staff To ensure that the office door does not pose a fire hazard by fitting a self-closing devise. To complete the fire risk assessment. Timescale for action 23/11/06 16/11/06 09/11/06 01/04/07 02/12/06 23/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA8 Good Practice Recommendations To involve relevant professionals and relatives if appropriate in the review process. To look at ways of increasing residents participation in running the home for example in the recruitment of staff. DS0000064029.V317856.R01.S.doc Version 5.2 Page 26 The Cedars 3. 4. 6. 7. 8. YA12 YA14 YA20 YA22 YA30 To look at encouraging residents to take part in a range of fulfilling activities. To look at providing and supporting residents to take part in more activities both in the home and in the community To provide residents with more comprehensive training in medication To develop the complaints procedure in a more userfriendly format. To provide staff with training in infection control The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 The Cedars DS0000064029.V317856.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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