Inspection on 28/07/05 for The Cedars

This inspection was carried out on 28th July 2005.

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

The inspector 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

The Cedars 04/09/08

The Cedars 06/11/07

The Cedars 22/01/07

The Cedars 29/11/05

The Cedars 21/02/05

The Cedars 23/08/04

The Cedars 18/03/04

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

CARE HOMES FOR OLDER PEOPLE Cedars (The) High Street Purton Wiltshire SN5 9AF Lead Inspector Thomas Webber Announced 28 July 2005 th 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. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Cedars (The) Address High Street Purton Wiltshire SN5 9AF 01793 772036 01793 772635 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) The Orders of St John Care Trust Mrs Diane Bowden Mrs Carol Anne Rickman Care Home 48 Category(ies) of LD(E) Learning Disability - over 65 (3) registration, with number MD(E) Mental Disorder - over 65 (6) of places OP Old Age (42) PD Physical Disability (7) Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of seven service users can receive intermediate care in the home at anyone time 2 Service users are only admitted under the category of Physical Disability in order to receive intermediate care within the home`s rehabilitation unit 3 Service users admitted under the category of Physical Disability must be over 60 years of age but not reached the age of 65 Date of last inspection 21st February 2005 Brief Description of the Service: The Cedars was built in the 1980’s as a purpose built residential home offering accommodation and personal care to residents with a variety of needs. This includes residents over the age of 65 who require care primarily through old age, residents with a learning disability or with a mental disorder aged over 65. The home can also accommodate up to 7 older people with a physical disability. The home is registered to the Orders of St John Care Trust and the registered manager is Mrs Carol Rickman.The home provides 38 places for long term care, 3 for respite care and 7 for rehabilitation. The home also provides day care facilities for up to 15 people from Purton and the surrounding areas. The Cedars is situated in the village of Purton and is in close proximity to the various amenities. The home provides all single accommodation for residents’ use and residents’ bedrooms are located on the ground and first floor levels and are serviced by a passenger lift. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, undertaken during the course of one day from 09:20 to 14:40. The inspection primarily focused on the direct care provided. A tour of the premises was undertaken and the views of twentyseven of the forty-eight residents in situ were sought on an individual and group basis, regarding the care and services provided by the home. The views of a visiting relative of a resident were also sought as part of the inspection process. The records in relation to residents’ contracts, assessments, medication, menus, complaints, staffing levels, quality assurance and residents’ finances were also checked. The timescale of the requirement previously identified at the last inspection relating to the home establishing an effective quality assurance system has been extended to ensure the process is completed. What the service does well: The residents and a visiting relative spoken to commented very positively with regard to the care and services provided. Residents benefit from living in a home, which is run and managed by a manager who is suitably experienced and qualified. The home is run in the best interests of the residents where opportunities exist for them and their relatives to comment on the quality of care and services provided. Residents spoken to commented very positively about the care provided by the staff, stating that the staff are very kind, helpful and they are well looked after. However, residents’ opinions differ about the ability of staff to spend quality time with them: some commented that staff are very busy and the home is short staffed whereas others felt that staff do have the time to spend with them. The visiting relative of a resident also spoke very positively about the care provided by the home. She stated that the home has created an open atmosphere, staff are very approachable, care is very good and her mother is very happy. Staff were observed to undertake their duties in a caring and attentive manner. Staff are provided with training opportunities to ensure they are competent to do their job. Residents are supported and protected by the home’s recruitment practices and suitable systems have been established to ensure that residents’ finances are appropriately safeguarded. Information is provided to residents on how to complain should they wish to and the residents felt confident that any concerns they may have would be listened to and suitably acted upon by management and staff. Appropriate procedures are in place to protect the residents from abuse. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 6 The health care needs of the residents are being suitably met. Suitable procedures are in place for residents to be responsible for their own medication where capable. Residents are treated with respect and their rights to privacy are maintained and residents can exercise personal autonomy and choice, within their capabilities. The home provides residents with a range of activities as well as the opportunity to pursue their own interests to meet their social, recreational and religious needs. Residents maintain contact with their families, friends and relatives in accordance with their preferences. Residents, within their capabilities, can exercise personal autonomy and choice. Residents receive a varied, appealing and balanced diet and the vast majority of them commented that they were very happy with the quality and quantity of food provided and confirmed that choices are available and they receive plenty of food. However, a few of them did comment that the meals did vary at times. Residents live in a safe and well-maintained environment where they have access to safe and comfortable indoor and outdoor communal facilities. Sufficient bath, shower and toilet facilities are provided. Residents’ bedrooms are of a good size which enable residents to personalise them to their individual wishes. The residents commented favourably about the level of accommodation provided. The home is maintained to a good standard being clean, tidy and comfortable and offers appropriate laundry facilities to meet the needs of the residents. Residents spoken to commented very favourably about the laundry arrangements in place, stating that their clothing is returned in good condition. 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. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 The home ensures that residents are provided with a written contract or the placing authority’s terms and conditions. Residents are also normally assessed, at least by the home, prior to admission to ensure that the home can meet their needs. EVIDENCE: All residents who are privately funded are provided with a copy of the Trust’s written contract and residents who are funded by Social Services are provided with a copy of the placing authority’s terms and conditions. Evidence was available to show that contracts had been established for those residents recently admitted and case tracked. The home obtains a copy of the community care assessment or other relevant documentation for those residents funded by Social Services. In addition, the manager or care leader also completes the home’s pre-admission long-term assessment/care plan tool. Evidence was available to confirm that these documents had been obtained/completed for those residents recently admitted and case tracked. The home’s assessment tool is completed either in the prospective resident’s own home or on visits made to The Cedars: wherever the person feels more comfortable. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8, 9 and 10 Residents’ health care needs are suitably met which includes maintaining control and responsibility for their medication where they have been deemed capable following a risk assessment. Residents feel that they are treated with respect and their rights to privacy are maintained. EVIDENCE: Residents are registered with one of two surgeries and have a choice of GPs within the practices. GPs from the Purton surgery hold surgery at the home on at least a weekly basis. Residents, who are able, attend the surgery for any appointments with transport and escort being provided. However, residents who receive any treatment at the home do so in the privacy of their bedrooms, although there are also occasions where minor issues may be discussed with residents in the privacy of the office within the day centre. Records are maintained of any visits made by the GPs and district nurses. Appropriate aids are provided for those residents with incontinent and/or mobility problems. Residents access other health care services such as dental, opticians, chiropody and hearing, as and when required. The home has established a medication policy and procedure, although this document is currently under review. The policy and procedure recognises the rights of residents to maintain control over their medication for those residents Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 10 who are deemed capable following a risk assessment. Evidence was available to confirm that some residents were administering their own medication. Care leaders and some care staff, who are deemed competent having received training, administer all medication to those residents who are not deemed capable of administering their own. The home uses the Lloyds Monitored Dosage system and examination of the drug sheets showed that they are being appropriately signed for medication administered. Observations and discussions with some residents confirmed that they are provided with their own bedroom and they can conduct all their personal affairs in complete privacy, including medical examinations and any treatment. Staff acknowledge and treat residents’ bedrooms as their own private area and knock before entering. Residents can lock their bedroom doors, can choose whom and where to see any visitors and their mail is given directly to them unopened. There is a payphone available for residents’ use or alternatively, residents can choose to have a telephone installed in their bedrooms and some of them have availed themselves of this facility. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The home provides residents with a range of activities as well as the opportunity to pursue their own interests to meet their social, recreational and religious needs. Residents maintain contact with their families, friends and relatives in accordance with their preferences. Residents, within their capabilities, can exercise personal autonomy and choice. Residents receive a varied, appealing and balanced diet. EVIDENCE: In discussions with residents it is apparent that they can choose where and how to spend their time and when to get up and go to bed. Residents have the opportunity to pursue their own individual interests as well as participating in the various organised activities and outings arranged by the home, should they wish to do so. Daily organised activities are provided by the home and the weekly programme of activities is displayed in the hallway. Residents also confirmed that organised activities take place with some joining in and others choosing not to, preferring their own or the company of others. Some residents also play cards together. A church service and holy communion is provided twice monthly for those residents who wish to attend and these services are advertised in the home’s newsletter, which residents are encouraged to contribute to and is also displayed on the home’s notice board. A hairdresser visits three to four times a week and books are available from the library. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 12 Visitors are welcome at any time during the day and a policy is in place and displayed in the home. The policy refers to residents maintaining contact with their family, friends and representatives and this is also contained in the home’s welcome pack. Residents can choose whom and where they wish to see their visitors either in the privacy and comfort of their own bedrooms or the communal rooms available. A visiting relative confirmed that she can and does visit at various times of the day and is always made to feel welcome when she visits. Observations and discussions with residents confirmed that they can exercise personal autonomy and choice. Residents can and have brought items of furniture and personal possessions to make their bedrooms more homely, they can choose what time to get up and go to bed, where to spend their time, where to eat, and what activities to participate in. They can handle their own financial affairs in the privacy of their own bedrooms, if they are capable. Residents confirmed that residents’ meetings are held, they find them useful and the meetings provide them with the opportunity to raise and discuss issues relating to the care and services provided. Copies of the minutes of these meetings are displayed on the residents’ notice boards. A satisfactory and varied five weekly menu is in operation, which provides a choice at all mealtimes with further alternatives available, if required, to take into account residents’ preferences. A cooked breakfast is available in the dining area on a daily basis for those residents who wish it. Drinks and snacks are also available at other times of the day. Residents can choose where to eat their meals, either in the dining area or in their bedrooms. The vast majority of residents spoken to commented favourably about the quality and quantity of food provided and confirmed that choices are available and they receive plenty of food. However, a few commented that some meals did vary at times. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Information is provided to residents on how to complain and they felt confident that any concerns they may have would be listened to and suitably acted upon. Appropriate procedures are in place to protect the residents from abuse. EVIDENCE: Each resident is provided with a copy of the home’s complaints procedure, which specifies how and who would deal with any complaint. The procedure provides contact details for the Commission for Social Care Inspection and informs complainants that they can contact the Commission at any stage should they wish to do so. The home has received one complaint since the last inspection, which related to the odour of parts of the home and the way she was treated when visiting. The complaint was investigated by the home and found not to be upheld and was suitably resolved. Residents are aware of how to complain and those spoken to stated that they had no complaints. However, residents and the relative spoken to felt comfortable that they could discuss any problems/concerns, if they had any, with the staff and they would be appropriately dealt with. The home has appropriate procedures for responding to suspicion or evidence of abuse and copies of the Wiltshire and Swindon Vulnerable Adults procedures have been obtained which are in line with the Department of Health Guidance “No Secrets” document. Copies of the shortened version of this document have been distributed to all members of staff. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 24 and 26 Residents live in a safe and well-maintained environment where they have access to safe and comfortable indoor and outdoor communal facilities. Sufficient bath, shower and toilet facilities are provided, although the shower facilities are now too small to meet the residents’ needs. Residents’ bedrooms are of a good size which enable residents to personalise them to their individual wishes. The home is maintained to a good standard being clean, tidy and comfortable and offers appropriate laundry facilities for the residents. EVIDENCE: The home is situated in a quiet location close to the centre of Purton. The home continues to be maintained to a good standard being clean, tidy, comfortable and provides sufficient heating, lighting and ventilation. The decoration and furnishing and fittings are also suitably maintained. The home continues to make improvements to enhance the residents’ living environment with further improvements planned. The building complies with the requirements of the local Fire and Environmental Health Officers’ Departments and there are no outstanding requirements or recommendations. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 15 The home provides a lounge/dining room with a drinks bar and small ‘shop’ also located within this area. This area is also used for entertainment and recreational activities. There are also two smaller communal areas located on the first floor, which can be used as sitting areas. There is a no smoking policy within the home. There are separate facilities for day care clients. There are very attractive grounds around the home with a patio area, benches and water features to the rear of the property which is used and appreciated by residents weather permitting. The home provides sufficient bath, toilet and shower facilities, although the two separate walk in shower rooms could still benefit from being re-designed and enlarged to meet the needs of the residents. This deficiency has been referred to property services within the Trust to be rectified but at the time of this inspection no date has yet been agreed for this work to be undertaken. None of the residents’ bedrooms are provided with en-suite facilities, although two residents have shared access to a shower and toilet. Residents’ bedrooms are of a good size and are suitably furnished, decorated and equipped to ensure their comfort and privacy. Residents can bring items of furniture and personal possessions to make them homely and residents have personalised their bedrooms to their individual wishes. Locks have been fitted to residents’ bedroom doors and residents have also been provided with a lockable storage space. A call bell system is installed in each room, which is used by residents to call for staff assistance. Residents spoken to commented positively about the cleanliness and level of accommodation provided. The home is maintained to a good standard being clean, tidy and free from offensive odours. There is a spacious laundry room located on the lower ground floor which provides suitable facilities to meet the needs of the home. A chute system is used to transport washing to the laundry from the floor above. Residents’ clothing is labelled for those who use the home’s laundry service to ensure that their garments are appropriately returned. Residents spoken to commented very favourably about the laundry arrangements in place, stating that their clothing is returned in good condition. A few residents’ families deal with these arrangements. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 16 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 and 30 The current staffing levels are insufficient to meet more than the basic and immediate needs of the residents. Staff are provided with training opportunities to ensure they are competent to do their job. Residents are supported and protected by the home’s recruitment practices. EVIDENCE: The deployment of staff for the home, apart from day care, ensures that there are six care staff on duty in the mornings with five on in the afternoons and evenings with three members of waking night staff on duty each night. However, this number also includes the care leaders. The day care unit provides spaces for up to fifteen clients per day, Monday to Friday, and there are two care staff on duty at all times. Although the home meets the staffing levels of the previous registration authority, concern was previously expressed by the Commission about the need to review the number of care hours allocated based on the size of the home, the changing and higher dependency needs of the residents being accommodated. In addition there was a need to review the role of the care leaders who undertake a number of administrative tasks, which would have been previously undertaken by the deputy or assistant mangers therefore removing some of their time from providing direct care to the residents. The manager reported that since the inspection the Trust has increased the number of care and housekeeper hours for the home. The Trust has also submitted a detailed staffing proposal to the Commission, which will be considered at a meeting in September 2005. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 17 Residents spoken to commented very positively about the care provided by the staff, stating that the staff are very kind, helpful and residents are well looked after. However, residents’ opinions differ about the ability of staff to spend quality time with them: some commented that staff are very busy and the home is short staffed whereas others felt that staff do have the time to spend with them. The visiting relative of a resident also spoke very positively about the care provided by the home. She stated that the home has created an open atmosphere, staff are very approachable, care is very good and her mother is very happy. Staff were observed to undertake their duties in a caring and attentive manner. The Trust has established a policy and procedure for the recruitment of staff and three staff files checked showed that appropriate recruitment processes are being followed. New staff cover the Trust’s induction and foundation programme over a period of six months. The home continues to ensure that staff undertake NVQ and other mandatory and specialist training in order to achieve a trained workforce. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 33 and 35 Residents benefit from living in a home, which is run and managed by a manager who is suitably experienced and qualified. The home is run in the best interests of the residents where opportunities exist for them and their relatives to comment on the care and services provided by the home. Suitable systems have been established to ensure that residents’ finances are appropriately safeguarded. EVIDENCE: The manager has appropriate management and supervisory experience in the care setting she manages. She undertakes periodic training to update her skills and knowledge and has successfully completed the NVQ 4 in Care and the Registered Managers’ Award. The manager has overall responsibility for the management of the home as set out in her job discription. A quality assurance system has been introduced and consists of an annual quality survey involving residents, relatives and advocates. On completion of the surveys a report will be produced which will identify both the positive and Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 19 any negative aspects relating to the care provided by the home. The results of the survey undertaken will be made available to all who took part in the survey as well as a copy being sent to the Commission for Social Care Inspection. The timescale for completion of this task to be undertaken has been extended to allow for the process to be completed. In addition to the annual quality survey, other monitoring systems include a six monthly residents’ review form and a monthly complaint and food forms. Residents’ meetings have been established on a three monthly basis which also enables their views to be sought as well as for them to raise and discuss any issues pertaining to the running of the home. The home has secure facilities for the safe storage of residents’ money and a spot check was carried out of the system which was found to be suitably maintained. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 2 x x 3 x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 2 x 3 x x x Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 21 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 33 Regulation 24(3) Requirement The responsible individuals must establish an appropriate and effective quality assurance system, which consults with all residents and their representatives at appropriate intervals. A report must be established of any such reviews with a copy being sent to the Commission for Social Care Inspection and available to residents. (Previous timescale of 31/08/05 has been extend to ensure compliance) Timescale for action 31/10/05 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 21 Good Practice Recommendations The registered individuals should strongly consider enlarging the shower facilities to ensure they meet the needs of the residents. Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 22 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire,SN15 2BB 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 Cedars (The) D51_D01_S28140_THECEDARS_V198438_280705_Stage4.doc Version 1.40 Page 23 - 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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