Inspection on 29/11/05 for The Cedars

This inspection was carried out on 29th November 2005.

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

The inspector 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 28/07/05

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 Unannounced Inspection 29th November 2005 10.00 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 Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cedars (The) Address High Street Purton Wiltshire SN5 9AF 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) 01793 772036 01793 772635 The Orders Of St John Care Trust Vacant Care Home 48 Category(ies) of Dementia - over 65 years of age (4), Learning registration, with number disability over 65 years of age (3), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (4), Old age, not falling within any other category (42), Physical disability (8) Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users are only admitted under the category of Physical Disability in order to receive intermediate care within the home`s rehabilitation unit. Service users admitted under the category of Physical Disability must be over 60 years of age. A maximum of eight service users can receive intermediate care in the home at any one time. 28th July 2005 Date of last inspection Brief Description of the Service: The Cedars was built in the 1980s 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, 3 residents with a learning disability, 4 residents with a mental disorder aged over 65 and or 4 residents diagnosed with dementia. The home can also accommodate up to 8 older people with a physical disability. The home provides 38 places for long term care, 3 for respite care and 8 for rehabilitation. The home also provides day care facilities for up to 15 people from Purton and the surrounding areas. The home is registered to the Orders of St John Care Trust. At the time of the inspection the registered manager’s post was vacant. However, this post is currently being covered by Barbara Newman, acting manger, who only works at the home for two days a week and Kathryn Maslen, Head of Care, who works at the home on a full time basis. 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 a passenger lift has been installed. Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, undertaken during the course of one day from 10:00 to 16:00. The inspection primarily focused on the direct care provided. A tour of the premises was undertaken and the views of nineteen residents in situ were sought on an individual and group basis, regarding the care and services provided by the home. The records in relation to the home’s administration and residents’ assessments, care plans, menus, complaints, staffing levels, quality assurance and health and safety 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 again been extended to ensure compliance. What the service does well: Residents live in a comfortable, clean and safe environment which is suitably furnished and decorated and provides them with sufficient communal space together with adequate toilet and bath facilities. Residents are provided with their own bedrooms which they have personalised to their individual wishes. Residents spoke positively about the standard and cleanliness to their bedrooms. Satisfactory laundry arrangements are in place and residents confirmed this by stating that their clothing is returned in good condition. The home is run in the best interests of the residents with opportunities being available to them to comment on the care and services provided by the home. Information is provided to residents on how to complain should they wish to and the residents felt that any concerns would be listened to and acted upon. The health, safety and welfare of the residents and staff are promoted and protected. Residents spoken to commented very favourably about the care provided by the staff, stating that the staff are very kind, helpful, patient and very good. Warm and supportive relationships were observed between the staff and residents with a nice degree of banter between them. Opportunities are available for residents to pursue social, religious and recreational activities. Residents are treated with respect and their rights to privacy are maintained at all times and residents can exercise personal autonomy and choice, within their capabilities. Residents receive a varied, appealing and balanced diet and meals are taken in a congenial and relaxed setting. The vast majority of residents spoken to commented very favourably about the quality and quantity of food provided and confirmed that choices are available and they receive plenty of food. Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 6 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) DS0000028140.V269223.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 Although residents are assessed at least by the home, prior to admission, the quality and content is insufficient to determine whether the home can meet the needs of the residents. Opportunities are available for prospective residents and their families to visit the home, prior to admission, to assess the quality of facilities and suitability of the home. Intermediate care is also offered by the home and provides adequate facilities and services. EVIDENCE: The policy of the home is to obtain a copy of the community care assessment or other relevant documentation for those residents funded by Social Services and all prospective residents are also assessed by the home prior to admission to ensure that it can meet their needs. Serious deficiencies were noted in respect to the two most recent residents admitted to the home and case tracked by the Commission. The admission details form was not fully completed, lacking key information and the long term needs assessment and care plan was poor, again, with some sections not completed. This document was also not signed and dated by both resident and the member of staff completing the form. The home did not appear to have received any information from social services confirming that the resident’s needs had Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 9 changed or remained the same since her last period of respite care at the home. As part of the admission process, residents and their families are provided with the opportunity to visit the home prior to admission to determine whether the home can meet their needs. Of the two most recent admissions to the home none have made use of this opportunity, although one had previously received periods of respite care at the home. The home provides eight places for residents who receive intermediate care in an area of the home known as the rehabilitation unit. However, the accommodation was not originally designed for this purpose, although the location of residents’ bedrooms has helped to create the feeling of a selfcontained unit. Residents who are accommodated within this unit use the main entrance to the home and share the same communal facilities as the rest of the residents accommodated. A member of staff from the main home is allocated to work in the rehabilitation unit on a daily basis and works along side the rehabilitation team. Residents receive a range of specialist services, including physiotherapy and occupational therapy, during their stay within the unit. Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 Residents’ care plans provide inadequate information and in some cases are poorly recorded and their needs are not clearly identified which could potentially put residents at risk. Residents’ privacy and dignity are respected at all times. EVIDENCE: Each resident is provided with a long term needs assessment and care plan. However, the quality of content was extremely poor in respect to two of the three residents most recently admitted. Not all sections of this document were completed and nor were they signed and dated by the resident and member of staff completing the form. Short term care plans were also not dated and signed. The admission details forms were also not fully completed lacking significant information such as what medication the resident was being prescribed, their weight and height and means of communication. A photograph of the resident had not been placed on the file of one resident and the date of admission had not been recorded on another resident’s file. One resident’s file did not confirm that a risk assessment had been completed and a manual handling assessment had not been fully completed. The poor documentation related to those who were admitted for respite care. However, there was greater improvement in respect to the documentation regarding a Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 11 resident who had been accommodated at the home for some time, although the resident’s long term needs assessment and care plan did not record personal details at the top of the form. 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 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) DS0000028140.V269223.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Opportunities are available for residents to pursue social, religious and recreational activities. Residents, within their capabilities, can exercise personal autonomy and choice. Residents receive a varied, appealing and balanced diet and meals are taken in a congenial and relaxed setting. Deficiencies were identified regarding the quality of meals provided at teatime. EVIDENCE: In discussions with residents it is apparent that they 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. Some residents confirmed that they join in the various organised activities within the home whilst others choose 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. A hairdresser visits three to four times a week and books are available from the library. Observations and discussions with residents confirmed that they can exercise personal autonomy and choice within their capabilities. Residents can and have brought items of furniture and personal possessions to make their bedrooms more homely. Residents can choose what time to get up and go to Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 13 bed, how and 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 and those who commented confirmed that they find them useful. The meetings provide residents 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 and this was evident during the inspection. However, some of the residents seem to be under the impression that they are encouraged to use the dining room for their meals unless ill. The main meal of the day was observed which was conducted in a relaxed and congenial atmosphere. The vast majority of residents spoken to commented very 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 less favourably about the quality of meals provided, particularly at teatime. The standard menu for teatime does not reflect comments received from the residents. This was referred to in the minutes of the last residents’ meeting dated 29th September 2005. There have been two complaints received about the issue of food, one from a resident and another from a relative of a resident. New menus are in the process of being produced. Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Information is provided to residents on how to complain should they wish to and the residents felt that any concerns would be listened to and acted upon. However, an area of weakness lies within the recording of the outcomes of complaints investigated. 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 two complaints since the last inspection: the resident’s complaint related to food and the relative’s related to food, staffing, cleanliness and skin complaint. The quality of investigation undertaken shows a lack of recorded outcomes and a letter needs to be given to the complainant (resident), which identifies the outcome and action taken. Residents are aware of how to complain and those spoken to stated that they had no complaints and felt comfortable to discuss any problems/concerns, if they had any, with the staff who would listen and take appropriate action. Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26 Residents live in a comfortable, clean and safe environment which is suitably furnished and decorated and provides them with sufficient communal space together with adequate toilet and bath facilities. However, the shower facilities do not meet the needs of the home and there are some deficiencies to the heating system. Some improvements are planned to enhance the residents’ living environment. Residents are provided with their own bedrooms which they have personalised to their individual wishes. Satisfactory laundry arrangements are in place. 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 lighting and ventilation. However, concerns were expressed by a few of the residents about the lack of heating to some parts of the home and this was endorsed within the minutes of the recent residents’ meeting and observations made during the inspection. The head of care also acknowledged that there have been problems and action has been taken to try to rectify the situation. The head of care was advised of the Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 16 need to monitor the levels of heating throughout the home and to ensure that sufficient levels are maintained. The decoration and furnishing and fittings to the home are also suitably maintained. However, there are plans for some refurbishment to the toilets and a bathroom to the ground floor accommodation with this work due to be started prior to Christmas. The carpet to one wing has been measured with a view of being replaced. The head of care has also made a request for the carpets to the corridors where work to the toilets are due to be undertaken to also be replaced. Roof guards were in the process of being fitted at the time of the inspection. The planned improvements, when completed, will enhance the residents’ living environment. The home provides sufficient bath and toilet facilities, however, concern was expressed about the lack of action taken by the Trust in re-designing and enlarging the two separate walk in shower rooms so they meet the needs of the residents. This deficiency has been already referred to property services within the Trust but at the time of this inspection there has been no date 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 and equipped to ensure comfort and privacy. Residents can bring items of furniture and personal possessions to make their bedrooms more homely and residents have personalised them to their individual wishes. Locks have been fitted to residents’ bedroom doors to aid privacy and residents have been provided with a lockable storage space within their bedrooms. Residents spoke positively about the standard and cleanliness to their bedrooms, although a few expressed concern about the level of heating. The home is maintained to a good standard being clean, tidy and in the main 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. Since the last inspection the number of laundry hours has been increased. 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) DS0000028140.V269223.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The current staffing levels are insufficient to meet more than the basic and immediate needs of the residents. EVIDENCE: The deployment of staff for the home, apart from day care, ensures that there is a minimum of six care staff on duty in the mornings with five on in the afternoons and evenings and three members of waking night staff on duty each night. The staff rota did show that there are occasions where these are increased to provide seven care staff on duty in the mornings and six on in the evenings. The above staffing levels exclude those hours worked by the acting manager, head of care and various ancillary staff employed but include those worked by the care leaders. However, the care leaders tend to spend their time during the day undertaking various administrative tasks, which would have previously been undertaken by the deputy or assistant mangers, therefore removing them from providing direct care to the residents. 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. Residents spoken to commented very favourably about the care provided the staff, stating that the staff are very kind, helpful, patient and very good. Warm and supportive relationships were observed between the staff and residents with a nice degree of banter between them. However, there was a difference in perception with regard to the level of quality time staff are able to spend with the residents. Some residents stated that staff do spend quality time with them whereas others stated that staff are not able to due to them Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 18 being short staffed. Even those residents who commented positively accepted that they could not have a bath more than once a week as there are too many residents. Concern continues to be expressed by the Commission about the need to ensure that there is a sufficient number of care staff on duty at all times providing direct care to the residents. This needs to be based on the size of the home, the changing and high dependency needs of the residents being accommodated and therefore enabling staff to provide a quality of care residents should expect, rather than staff being only able to meet the immediate care needs of the residents. Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 38 The home is run in the best interest of the residents with opportunities being available for them to comment on the care and services provided by the home. The health, safety and welfare of the residents and staff are promoted and protected, apart from areas relating to fire prevention. EVIDENCE: A quality assurance system has been introduced and consists of an annual quality survey involving residents and their relatives. On completion of the surveys a report will be produced which will identify both the positive and any negative aspects relating to the care provided by the home. The results of the survey undertaken should 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. However, this has still not yet been achieved and the timescale for completion of this task to be undertaken has been further extended to allow for this process to be completed. In addition to the annual quality survey, other monitoring systems include a six monthly residents’ review form and monthly Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 20 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. Safe working practices have been established within the home, which comply with the relevant legislation. Full health and safety policies and procedures are in place to ensure a safe working environment. There is an ongoing training programme for all staff to receive mandatory training. Various electrical testing and servicing to equipment has been carried out. Radiator covers and window restrictors have been fitted for the protection of residents. However, examination of the fire log book showed that the home needs to ensure that all staff receive fire instruction on a quarterly basis and the date is always recorded when this is received. Other deficiencies include the need to carry out the various checks in relation to fire prevention as detailed within the fire log book, some having not been done since September 2005. Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X 2 X X 3 X 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 22 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 OP3 Regulation 14 Timescale for action The registered individuals must 12/12/05 ensure that the admission details form is always fully completed and that all sections of residents’ assessments are fully completed and in sufficient detail. The assessment form must also be signed and dated by both the resident and member of staff completing the form. The registered individuals must 12/12/05 ensure that residents’ care plans are always fully completed and in sufficient detail and that these documents are signed and dated by both the resident and the member of staff completing the form. The registered individuals must 12/12/05 ensure that residents’ manual handling and risks assessments are completed where specific risks have been identified. The registered individuals must 12/12/05 ensure that all records of complaints investigated clearly record the outcomes and any action taken. Complainants must always be informed of DS0000028140.V269223.R01.S.doc Version 5.0 Page 23 Requirement 2. OP7 15 3. OP7 17(1)(a) 4. OP16 22(3) Cedars (The) 5. OP19 23(2)(p) 6. OP21 23(2)(a) 7. OP27 18(1)(a) 8. OP33 24(3) 9. OP38 23(4) these in writing. The registered individuals must ensure that all parts of the home are provided with sufficient heating at all times. The registered individuals must ensure that the shower facilities meet the needs of the home. The Trust must submit a written proposal to the Commission for Social Care Inspection detailing when this upgrade will be undertaken. The registered individuals must ensure that there are sufficient numbers of care staff on duty providing direct care to meet the needs of the residents. The Trust must submit a written proposal to the Commission for Social Care Inspection detailing how this will be achieved. 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 timescales of 31/08/05 and 31/10/05 have not been met and the timescale has been extend to ensure compliance) The responsible individuals must ensure that all fire precaution checks, including instruction, are carried out within the appropriate timescales as detailed within the fire log book. 12/12/05 06/01/06 06/01/05 06/01/06 12/12/05 Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 24 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 Cedars (The) DS0000028140.V269223.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham 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. 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