Inspection on 04/09/08 for The Cedars

This inspection was carried out on 4th September 2008.

CSCI found this care home to be providing an Adequate service.

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 06/11/07

The Cedars 22/01/07

The Cedars 29/11/05

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 05/12/2008.

CARE HOMES FOR OLDER PEOPLE Cedars (The) High Street Purton Wiltshire SN5 9AF Lead Inspector Alison Duffy Unannounced Inspection 10:00 4 September 2008 th 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.V369607.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 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 manager.thecedars@osjctwilts.co.uk The Orders Of St John Care Trust Mrs Michelle Lisa McKeever Care Home 49 Category(ies) of Dementia (12), Mental disorder, excluding registration, with number learning disability or dementia (4), Old age, not of places falling within any other category (42) Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia- Code MDmaximum of 4 places Dementia- Code DE- maximum of 12 places Old age, not falling within any other category- Code OP- maximum of 42 places The maximum number of service users who can be accommodated is 49. 6th November 2007 2. Date of last inspection Brief Description of the Service: The Cedars was built in the 1980s as a purpose built residential care home. Originally managed by Wiltshire County Council, the home is now registered to the Orders of St John Care Trust. Mrs Michelle McKeever is the registered manager. The Cedars is situated in the village of Purton and is in close proximity to the various amenities. Peoples bedrooms, which offer single occupancy, are located on the ground and first floor. A passenger lift is in situ. There is a large dining room and adjoining lounge. Additional seating areas have been created within the main entrance and within some areas of the corridors. Staffing levels are maintained at one care leader and five carers in the morning and one care leader and four carers in the evening. In addition there is a head of care. At night there are three waking night staff. There are also housekeepers, catering staff, an activities organiser, a maintenance person and an administrator. Designated staff work in the home’s integral day centre. Fees for living in the home are based on dependency levels and the type of room occupied. The fees range from £407.85 to £550.00. There is an additional supplement for premier en-suite rooms. Items such as chiropody, hairdressing, Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 5 dry cleaning and personal items are not included in the fee. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection took place over two days. The first day took place on the 4th September 2008 between the hours of 10am and 6.15pm. The second day was on the 23rd September 2008, between 10.30am and 5.30pm. There were two inspectors, on the first day of the inspection. Ms Alison Stenning and Ms Debra Yeates, both locality managers and Mrs McKeever received feedback. The pharmacy inspector visited to look at the medication systems. The findings of this visit are detailed within this report. We met with people who use the service in their own rooms and within communal areas. We met with the staff members on duty. We looked at the management of peoples’ personal monies. We observed the serving of lunch and the evening meal. We looked at care-planning information, training records, staffing rosters and recruitment documentation. As part of the inspection process, we sent surveys to the home for people to complete, if they wanted to. We also sent surveys, to be distributed by the home to peoples’ relatives, their GPs and other health care professionals. The feedback received, is reported upon within this report. We sent Mrs McKeever an Annual Quality Assurance Assessment (AQAA) to complete. This was completed in detail. Information from the AQAA is detailed within this report. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people using the service. What the service does well: People are able to follow their preferred routines. This includes how and where they spend their day, what time they get up and whether they have meals in their room. Most medicines were stored safely and managed by trained staff. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 7 People are able to personalise their own room and spend time, on their own as they wish. Visitors are welcomed and hospitality is evident. People are clear about the ways in which they can raise any concerns. The environment is of a good standard and well maintained. Training is given priority and ranges of subjects, other than those, which are mandatory, have been arranged. Robust recruitment procedures are in place and a high level of health and safety material is available for staff reference. What has improved since the last inspection? What they could do better: Care plans must be fully completed and written in greater detail to ensure staff have the required information to meet people’s needs effectively. Control measures to minimise people’s risk of developing a pressure sore and weight loss, must be evident within care planning information. Written guidance to staff about medicines administered ‘when required’ must be further developed. Some medicine storage arrangements need to be upgraded. Practices of when staff administer some medicines, need reviewing. Measures must be taken to ensure staff are aware of how their interactions with people affect matters such as privacy, dignity and general wellbeing. Staff must ensure that call bells are answered without delay. A review of accidents is needed to ensure future incidents are minimised. Staff must record more detailed entries in the accident book in order to evidence each incident. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 8 There have been a high number of thefts within the home. These have been appropriately reported to the local Police and Safeguarding Unit. While strategies have been agreed to address the thefts, so far the perpetrator has not been caught. 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. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 9 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.V369607.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are assessed before being offered a service, so are assured that their needs will be met. EVIDENCE: Within the AQAA, we saw that a robust assessment process is followed before a person is considered suitable for the home. The AQAA stated ‘all prospective residents are assessed prior to admission by a staff member who is trained and qualified and is able to ensure that we are able to meet the needs of the individual. Information is gathered from many sources, including the individual, family members, social workers and GP’s. We encourage prospective residents and their families to visit the home, at a time of their choosing, so that they see the home and their room prior to making a decision.’ One person told us their family had visited a number of care homes in the area. They had selected The Cedars as it was friendly, clean and the staff Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 11 seemed nice. They chose not to visit but moved in on the advice of their family. The person told us they were happy with their decision and said ‘I haven’t looked back.’ Another person told us ‘I didn’t need to visit. I’ve had friends here in the past so I knew what it was like. They wouldn’t have got me anywhere else. I knew it would be a good place to come.’ Another person said ‘they came and did an assessment at home, then one month later in GWH [Great Western Hospital.]’ Another person told us ‘I just ended up here from hospital.’ Within a survey, a care manager told us ‘it has a happy and welcoming atmosphere. It is the first choice for residents who have lived in Purton/Cricklade for all their life and therefore many residents have known each other from their younger days.’ At the last inspection we made a requirement that the admission details form must be fully completed and insufficient detail. The requirement had been addressed. We saw that a new assessment format was in place. The assessments we saw had been transferred on to this format from previous documentation. The assessments gave basic information about people’s needs. Some of the format used a tick style approach. Mrs McKeever told us that staff had received training on the completion of the documentation. She said they were aware of the need to clarify the ticked answers with further written information. Each person had a nutritional, tissue viability and falls assessment in place. The Cedars does not provide intermediate care, so standard 6 is not applicable to this service. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans did not fully reflect people’s needs. Measures to minimise some people’s risk of developing a pressure sore and weight loss were insufficiently addressed. There were generally safe arrangements in place for the management of medicines yet some weaknesses need review, so people are protected from unnecessary risks. Some aspects of service provision compromised people’s privacy and dignity. EVIDENCE: Ms Stenning and Ms Yeates told us that the Trust was in the process of auditing all care plans within all of its services. Ms Stenning said an action plan had been developed in response to any shortfalls in the content and quality of the plans. Mrs McKeever told us that this had been a positive exercise. She said staff were beginning to work through the action plans to ensure the improvement of care planning. We saw that some of the care plans, which had not been audited, contained brief accounts of people’s needs. There were statements, which needed Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 13 clarification. For example, one plan stated ‘to remain independent to her own limitations. Staff to encourage XX to use her independence as much as possible.’ The plan continued to state ‘all transfers should be done with XX’s permission and two staff to ensure hoist sling is placed correctly at all times.’ We said clear, specific information was needed to ensure staff had the required information, to support the person effectively. We saw within one plan that the person needed assistance to go to the toilet, three times a day. There was little information about the times of the day or the support required. The plan stated ‘tendency to constipation, mediation to be taken.’ It was not clear what the medication was, when it was to be taken or when medical intervention was potentially required.’ We saw little evidence that additional control measures such as encouraging fresh fruit, was in place. We saw that one person had a catheter. Other than ‘report any changes to catheter care to care leader’ and ‘night bag to be connected every night’ there was minimal information about the management of the catheter. Within one plan ‘suffers from dementia and has a very short term memory loss’ was stated. There was no information as to how this affected the person’s daily life. It was stated ‘staff to give reassurance if XX becomes slightly confused and misunderstood.’ Without clarity, it was not clear what sort of reassurance the person benefited from. There were some aspects of care plans, which had not been completed. This included mobility, promoting continence, emotional wellbeing and promoting safety and risk. Some tissue viability, manual handling and nutritional assessment formats, had not been filled in. Within two care plans nutrition had not been addressed in the care plan, despite the identification of a risk of malnutrition. We saw that one nutritional assessment identified the need for the person to be weighed on a weekly basis. This had not been undertaken. We saw that one person had lost weight. Documentation stated ‘has lost quite a bit.’ The action taken stated ‘observe.’ We saw that some documentation gave conflicting information. For example, within a care plan it identified that the person was able to walk with their frame at all times with two carers. The manual handling assessment stated ‘for standing and walking, requires one carer.’ We saw that the person had had a fall. The falls risk assessment identified no risk of falling. The manual handling assessment stated ‘needs help from a carer as may loose balance.’ We saw clearer recording within one care plan in relation to supporting a person with their drink. The information highlighted the use of a thickener and a straw and the need for supplement food drinks. Due to their frailty, we saw that one person spent the majority of their time in bed. The tissue viability assessment and the core care plan headed ‘pressure care’ had not been completed. In the care plan, which addressed resting and sleeping, it was stated ‘needs to be turned 4 hourly to relieve pressure areas.’ Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 14 There was no other information as to the strategies in place, to minimise the risk of the person developing a pressure sore. Another care plan stated ‘to observe skin condition on a daily basis and report to DN any change in health or skin condition. Moisturise skin as required with cream that has been prescribed by Nurse of GP.’ We said that this did not enable staff to have sufficient information to manage the condition of the person’s skin. Within another care plan, it was stated ‘if pressure areas break out, care leaders to seek further advise from DN.’ We saw minimal information as to the measures staff should take to promote healthy skin. We saw that staff had recorded specific details about the condition of a person’s skin, within their turning chart. The information had not been cross-referenced to the person’s daily records. People told us that they were happy with the care they received. Specific comments included ‘they help me to bath but I make the bed, I don’t use the call bell really,’ ‘night staff will help me to bed when I choose to go, I just tell them’ and ‘I’m as happy as I can be.’ Within a survey one person said ‘I’m very happy with the care I receive.’ Mrs McKeever told us that the home has a good relationship with the local GP surgeries. The GP’s and the district nurses regularly visit and are available as required for advice. One person told us ‘I’m waiting for the nurse to come today and dress my leg, she came on Monday but sometimes they want doing in between.’ Within surveys, people told us they received the medical support they required. One person said ‘they sort me out pretty well.’ Staff who have undertaken special training in the safe handling of medicines were responsible for the management and administration of medicines for people living in this home. These staff also completed practical assessments of their competency as part of the training programme. Some care leaders were also attending a more advanced medication training course. A local pharmacy supplied most of the medicines and many of these were dispensed in special blister packs called a monitored dose system with a fourweek supply of each medicine. These packs help staff to see easily what medicines need administering on a particular day and time and what medicines have been administered. As part of this system the pharmacy each month printed a record of all the medicines the doctor has prescribed with a chart on which staff recorded when they have administered each medicine. Staff generally recorded the medicines received into the home on these charts. Two staff members signed for any handwritten amendments on the charts as a check that these were copied correctly. We saw that the allergy sections of the medicine records were completed but noted for two people this stated ‘none known.’ The care notes indicated allergies to antibiotics. It is important to liaise with the pharmacy with this sort of information so that the medicine Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 15 charts are printed correctly. This could provide an important check to help prevent people having medicines that they are allergic to. There were photos with each record to help the staff to check they were giving the medicines to the right person. There were additional recording sheets for medicines with a variable dose or only used ‘as required.’ There were two other recording sheets for creams and ointments applied topically. There were separate records for medicines disposed of via the pharmacy. Staff recording these returns need to make sure that the records include the strength and formulation of each medicine so that it is quite clear what was returned. We found that most of the various medicine charts were generally properly kept so that there were clear records about the medicines people living in the home had taken. We found two examples of gaps on two separate administration records. We did not know if the medicines were correctly administered. We pointed these out to staff. In one case, teatime doses of a particular tablet for one person were not signed as administered the two days before this inspection, yet the tablets were missing from the pack. A member of staff confirmed they had in fact administered these doses. Some of the records about creams and ointments staff had applied were kept inconsistently. We could not always tell if the prescribed treatments were used. We discussed consideration of alternative ways for recording these treatments, as the number of records in use at present, made this complicated. We pointed out to the manager that the holes punched on the left side of the medicine charts (for filing purposes) were obscuring some important details about the medicines. We saw evidence of stock counts for packs of medicines carried forward from the previous month on to the current medicine charts. This is a good practice to help with controlling stocks of medicines and helps with checking that the right amounts of medication have been administered. The records indicated that all the medication people needed was in stock at the time of the inspection. Some people living in the home were able to manage their own medicines. They were provided with a lockable space in their rooms in which to keep these medicines. We visited two rooms and found that the medicines were just left out on the side. One person told us that s/he always kept the door to the room locked. S/he said that staff always obtain new supplies of medicines when s/he is running out. She always has the medicines needed. In another room (that was unlocked) there were various containers of creams and ointments left out on the side. They did not have any dates, when they were opened, written on them. The manufacturer’s direction for storing one of the creams was below 15°C. This effectively means, in a fridge. We could not find a risk assessment for this person about these arrangements. This is needed for any person living Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 16 in the home who looks after their medicines to make sure of their own safety and that of everyone in the home. We found risk assessments for two other people who were looking after their medicines. We advised that more information would be helpful in these. We looked in more detail at the medicines and care records for eight people living in the home. New style care plans were being introduced; this was also in progress at the last inspection. We found that care plans did not always contain sufficient or any information to direct staff about the use of certain medicines, particularly where a variable dose or a dose to use ‘as required’ was prescribed. One particular example was the lack of detail about the use of a strong analgesic medicine. On some records the strength of the medicine was not included. There were differences about the number of doses and the time administered between the two record charts and the record book. This would make it really difficult to know what medication this person had received which could put them at risk of receiving the wrong amounts of this medicine. The same person was also taking a complicated pattern of other medicines throughout the day. A clear plan was needed for this, as information on file varied from the doses printed on the medicine containers and medication chart. This could lead to confusion about the right treatment needed. We saw two members of staff administer some medicines to people living in the home (who mainly at this time were in the dining room) at lunchtime and teatime. The member of staff quite often asked people about their need for medicines such as painkillers. These people were often at various stages of eating their meal. We discussed with the manager about finding out about each person’s choice about where they wanted their medicines and if it respected their dignity and privacy. For example, we saw a member of staff support a person with their inhaler at the dining room table. We saw that staff signed that the medicines were administered before people had actually taken them. We acknowledged that staff did keep a watchful eye to see that they were taken. We saw that sometimes medicines were left in a cup beside one person at a table in the presence of others. This may be a risky practice, as sometimes other people at the table may mistakenly take the wrong tablets. We discussed these points with the member of staff and the manager. The member of staff had a good awareness of people’s particular needs for medication and was careful, for example, not to offer medication containing paracetamol within four hours of the previous dose. Medicines were stored safely and well organised in locked units and at the right temperature. The medicine fridge was in an office that staff said would be kept locked. As the office is used by a number of staff there is no guarantee that it will always be locked when unattended and may therefore allow uncontrolled access to medication kept in the fridge. This needs fitting with a separate lock. Eye drop containers were dated when first opened to use. These were replaced every month to reduce risks from using contaminated drops. We pointed out Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 17 that most of the eye drops in use did not need to be in the fridge as it would be more comfortable to people receiving the drops for these to be at room temperature. We found one medicine in the main storage room that should have been kept in the fridge before use in order to retain the right potency. The manager immediately wrote a reduced shelf-life on the box in accordance with the manufacturer’s directions. Containers of creams or ointments that were opened for use were largely kept in bedrooms. This arrangement must be checked as being safe for everyone in the home. We looked at the storage and recording arrangements for controlled medicines. The cupboard used for these was constructed to an old standard and did not comply with The Misuse of Drugs (Safe Custody) Regulations 1973. This needs upgrading in order to store these medicines safely and in accordance with the law. Checks we made in the record book were generally accurate. We found some pages did not contain information about the strength of the medicine involved. We found certain information of the doses administered was not the same as contained in the individual record charts (see above). Staff had not written the opening date of one liquid medicine that has a limited period of use of 90 days. The manager dealt with this by reference to the record book. In discussion, the manger told us there were no equality or diversity issues that would impact on medication. There was a medication policy and procedures available so that all staff were aware of how the company expected medication to be handled in a safe way. There were individual protocols for using homely remedies written for specific people living in the home. Within a survey, a person using the service told us ‘I am very happy living at the Cedars, I like all the staff and they all treat me with respect.’ Within the AQAA, it was stated ‘all staff at the home are trained to appreciate the need to respect privacy and dignity and how to achieve this in their daily work activity. All residents are asked how they wish to be addressed and this is followed through in all their documantation, bedroom signage and approach from staff.’ We saw that people’s preferred form of address and their preference of wanting a male or female carer to provide their intimate personal care, were highlighted with care plans. We saw that one plan plan stated ‘XX to be given privacy when required.’ We advised that greater clarity be given to this statement. While we saw staff knocking on people’s doors before entering, there were interactions, particularly in the dining room, which did not promote people’s dignity. We saw a member of staff say ‘will you go to the table for your dinner please XX. Go and sit over there.’ Another person asked for some more lunch. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 18 The staff member said ‘it’s all gone.’ The person repeated the request and another member of staff said the same. The interactions were brisk and did not include any further discussion with the person. We saw that the staff were talking and joking between themselves yet there was very little interaction with people using the service, during the lunch time period. We saw a member of staff pull a chair from the dining room table to assist a person, to sit down. They started talking to a colleague and did not react to the person, who did not have enough space to manoeuvre themselves, between the table and the chair. Later in the day, a person repeatedly shouted loudly, ‘I want to go to bed, I want to go to bed.’ We saw staff walk past the person without responding to them. Mrs McKeever told us that these interactions were totally out of character. She said the staff always showed positive relationships with people and were friendly and animated, with lots of banter. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 19 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People appeared content to follow their own solitary interests yet greater allocation of activity hours would further enhance opportunities for people. People are able to follow their preferred routines and receive visitors as they wish. People gave variable views about the food provided so a review of meal provision would be beneficial to ensure greater satisfaction. EVIDENCE: Within the AQAA, it states ‘the Activity Coordinator is the champion of social activity in our home. The staff team support this role and particpate fully.’ The home has 20 hours allocated to activity provision. Mrs McKeever told us that she has requested additional hours in order to develop more opportunities for people. We saw an activity planner on the notice boards in the corridors. This contained actvities such as music and movement, bingo and board games. We saw a year planner, which highlighted activities in relation to calendar events. Aspects such as sunflower judging were included. There were photographs around the home of events, which had taken place. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 20 We did not see a high level of organised social activity within the home. People told us that they chose to follow their own solitary interests, within their room. They said staff respected their choice of doing this. One person told us ‘I go to activities, when they are on. We had the Pearlies here and some evenings we play cards.’ Another person said ‘I went out for a meal yesterday with my XX. A friend also comes on a Tuesday and takes me to Cricklade. I join in all the activities. We have singers in and there is bingo, but I don’t play that.’ One person told us about the hairdresser. Another person told us ‘we have a library down the road so when I go to the post office I go there. We also have books downstairs.’ Another person said ‘the activities are not everyone’s cup of tea.’ Within surveys, one person told us ‘I enjoy bingo and the musical entertainment.’ Another said ‘I enjoy my own room where I can enjoy my needlework but take part in activities when I wish to.’ A care manager told us ‘there is a happy atmosphere. Visitors are made welcome. Hobbies are encouraged. Residents meetings give choice – e.g. menus.’ People told us that they could have visitors at any time. They could entertain in their own room or in the communal areas. One person told us ‘my family bought me a telephone with large numbers so that I can keep in touch with them.’ People told us that they could follow their preferred routines. They could get up and go to bed when they wanted to. They could have meals in their room and spend their day, as they chose. Mrs McKeever told us that regular meetings are held to encourage people to give their views on the running of the home. We saw within one care plan that the person chose to stay in bed for long periods. The entry stated ‘XX likes to rest and sleep most of the day. Staff will only go in to give drinks, personal care or to give XX food as required. XX is left to sleep throughout the day.’ While recognising the person’s choice, further attention should be given to this person’s quality of life. As stated earlier in this report, one person repeatedly shouted ‘I want to go to bed. I want to go to bed.’ They were unsettled and agitated yet staff did not engage with them. The person was not supported to enable their wellbeing. We received mixed feedback about the food. Specific comments included ‘the food is good on the whole’ and ‘it’s very nice food, plenty of it.’ One person said ‘there is a good variety and choice of meals. I have my meals in my room and it is hot when it arrives.’ Another person said ‘sometimes it could be better but when you get older you have to have what you are given.’ Another person said ‘sometimes it’s a bit of the same but we get by.’ One person commented that the kitchen is always running out of things. We saw on the first day there was no tea on the coffee trolley in the morning, as there were no teabags. On the second day, there was no cheese. A member of the kitchen staff went out Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 21 to get some. One person said ‘it’s the same old thing. It’s often cold and not what we’ve always been used to, like pasta. We never have ham. We are given spam and corned beef.’ Within surveys, there were further comments about the food. These included ‘sometimes good – sometimes not,’ ‘sometimes it could be better’ and ‘could be improved.’ Another person told us ‘the food could be a lot better. The food is overcooked. Puddings - not a lot of variety.’ Some people gave positive comments about the food. They said ‘I always leave my plate empty. I enjoy the food I get,’ ‘I usually enjoy my meals, as long as the portions are not too large’ and ‘I get on very well with the food served.’ On the day of the inspection the meal was lamb hot pot or vegetable burger, cabbage, cauliflower and boiled potatoes. The meal looked appetising and was served according to individual appetites. We saw that two people ate very little of their meal. Their plate was taken away. The member of staff did not ask whether they wanted anything else or if there had been a problem with the meal. One person told us they had their meal liquidised. We saw that one person asked for some more hot pot. A staff member said ‘its all gone.’ There were no comments about the person enjoying the meal or if they wanted anything else. We saw that after people had been served their dessert, the shutter separating the dining room and the kitchen was pulled down. There were no staff in the dining room at this time. Mrs McKeever told us that the shutter was pulled to minimise the noise from the kitchen. She said this had been agreed at a residents meeting. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 22 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are aware of how to make a complaint. Adult protection systems are in place yet people are at risk of financial abuse due to the high levels of ongoing thefts within the home. EVIDENCE: Within the AQAA, it states ‘the Trust has a robust and open approach to responding to complaints. There is a policy and procedure in place and all staff are encouraged to respond in a helpful, non judgemental and sympathetic manner.’ Mrs McKeever told us that she has an ‘open door’ policy to create an informal approach, which enables people to raise issues more comfortably. She said she encourages people to raise any issues so that they can be quickly addressed. We asked people what they would do if they had a concern about the service. One person said ‘nothing to complain about, it’s ok, relaxed and I have everything I need. Never had any trouble here.’ Another person said ‘I’ve got no worries or complaints.’ Other views were ‘I have no complaints, I would go to speak to Michelle or Eileen’ and ‘I would tell my daughter if I had a complaint.’ Within surveys, people confirmed that they knew how to raise a concern. Specific comments included ‘I know I can contact my key worker or talk to the Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 23 manager,’ ‘I would talk to my family or the manager or both’ and ‘care leader or any member of staff. Also the manager.’ We saw that a record of formal complaints is maintained. Documentation detailing the complaint, the investigation and the outcome were clearly identified. We saw that issues had been satisfactorily addressed with concerns upheld if required. There was evidence of what had been done to ensure the matter would not happen again. We did not see evidence of complaints, which had been raised on a day-to-day basis. Mrs McKeever told us that these concerns would immediately be addressed yet they are not always documented. We advised that action to address any concern, should be fully recorded, as evidence that complaints are taken seriously and resolved as quickly as possible. Staff told us that they would immediately report any suspicion or allegation of abuse to Mrs McKeever. They said if Mrs McKeever was not available, they would contact the Trust’s main office. They told us they had received adult abuse training. Within the AQAA, it was stated ‘all staff receive a copy of ‘No Secrets’ and attend The Vulnerable Adults Training from the time they start work with the Trust. All have been through the POVA and CRB process and have a clear undertstanding of their responsibility to inform of any form of abuse or threat to the residents.’ While acknowledging that systems are in place to safeguard people from abuse, there have been a very high number of thefts within the home. All have been appropriately reported to the Police and the local Safeguarding Adults Unit. Mrs McKeever told us that strategies have been agreed to address the thefts yet so far the perpetrator has not been caught. We saw that a resident’s meeting had been held to inform people of the thefts and the need to be extra vigilant. Mrs McKeever told us that people are encouraged to keep all valuables securely stored. People are able to use the home’s safe if required. A number of people told us about the thefts and the emotions, which have been raised. One person said ‘they first took money from my wardrobe, so the family bought me a safe but they still got into it and took money. My wallet is now empty, everything is in the safe and the number has changed. The girls are all lovely and you can’t imagine anyone doing it’. Another person said ‘I had money taken from my handbag. It’s been reported. I have had two lots taken. Michelle has spoken to me. I now have a locked drawer, my XX puts my money in the office safe for me.’ Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from an environment that is clean, well maintained and furnished to a good standard. EVIDENCE: People have a single bedroom on the ground or first floor. There is a passenger lift or various staircases giving access to the first floor. Those rooms visited were personalised to a high degree. People had brought items of furniture with them, on admission. All had a number of important possessions including pictures and photographs. Some people had their own telephones and a key to their room. People told us they were very happy with their room. Specific comments included ‘I’ve got a nice outlook and it’s very light in here,’ ‘it’s cosy and I have everything I want’ and ‘I like my room its peaceful, I don’t want to go to the dining room or lounge’. We saw that some people chose to spend large Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 25 amounts of time in their room. People told us that staff respected their wishes and they did not feel pressurised into spending time in the communal areas. We saw that the communal areas were comfortable and maintained to a good standard. The recently refurbished hairdressing room creates a positive space for people. There is a yearly major maintenance and refurbishment plan. Within the AQAA it was stated ‘we have recarpeted and decorated six bedrooms, redecorated the entrance hall and two stair cases. Our hairdressing salon has undergone a major refurbishment offering more comfortable and pleasant surroundings. New garden contractors have been instructed and improvements are being made to the general appearance of the grounds. Two thirds of the roof has been replaced with new tiles.’ We saw that a further twelve bedrooms and the toilets on the ground floor are due to be refurbished. Two additional en-suites are being created and the carpet on the first floor corridor is due to be replaced. Mrs McKeever told us that the ‘shop’ is to be redecorated and a vegetable plot is being developed. The AQAA confirmed that all hot water outlets have regulators to ensure a safe temperature is maintained. We advised that these be checked more regularly as the hot water from three outlets, were above the recommended levels of 43°C. Mrs McKeever told us that the maintenance person regularly monitors the hot water temperatures. She said she would ensure these outlets were rechecked. We saw that the environment was clean and tidy. Within a survey, one person told us ‘sometimes I think the cleaners could be a bit more thorough.’ Other people told us they were happy with the cleanliness of the home. One person said ‘they are very good, excellent at keeping my room clean.’ Another person said ‘it’s like a posh hotel, no complaints at all.’ Mrs McKeever told us that there are generally four housekeepers on duty during the week. At weekends there are three. A new post of head housekeeper has been devised. Mrs McKeever told us that the housekeepers work well as a team and take pride in their work. Due to this, the standard of cleanliness is always to a good standard. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While staffing levels have been increased, it is the experience of some people that they have to wait for staff assistance. People are protected by a robust recruitment procedure. Training is of a good standard yet some staff interactions do not promote people’s wellbeing. EVIDENCE: We saw that staffing levels were maintained at generally at six staff on duty in the morning. There were five in the evening. In addition to this, some shifts had a care support worker. Mrs McKeever told us that from September 2008, the home had been allocated a head of care. She said this post had made a significant difference to the time available to spend with people using the service. The staffing rosters demonstrated that there were three waking staff on duty each night. Mrs McKeever told us there were currently some staffing vacancies. Existing staff members and agency staff were covering these. Mrs McKeever told us that confirmation regarding the prospective staff members’ suitability of working with vulnerable people was being awaited, before they commenced employment. One person felt the home could do with more staff. Another said there were enough staff. Other views were ‘well they are busy but we don’t get forgotten’ and ‘they come when I need them.’ Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 27 Within surveys, five people told us that staff were usually available when needed. They said ‘sometimes I have to wait a while’ and ‘sometimes we have to wait if you call but they can’t be everywhere.’ Further comments included ‘you can’t expect them to always be available. They always respond to my buzzer,’ ‘s/he appreciates that there are other people to be looked after besides her/him’ and ‘I think they are all pretty good.’ One person said ‘if they are very busy at the time, they will always come back to attend to a request.’ Within a transfer from hospital letter, it was detailed that XX needed regular toileting. The person told us they needed the toilet at 11.53am. We rang the call bell for the person. Staff arrived at 12.02. The person said ‘this often happens.’ The person’s care plan highlighted that they needed the help of a carer to use the toilet. Within daily records, we saw two entries whereby the person was upset about the need to wait for staff assistance. One entry stated ‘XX upset as staff told him/her to wait to go to the toilet.’ On the first day of the inspection we saw that XX was sat at the dining room table from 12noon until 3pm. Staff did not ask the person if they needed to use the toilet. We saw another person, in a wheelchair who remained at the dining room table from 12noon until we informed Mrs McKeever at teatime. They did not receive any assistance from staff during this time. Another person, asked for their zimmer frame after finishing their lunch. They did not receive their frame until approximately half an hour later. One person told us that they sometimes had to wait before being assisted to bed. They said that one night they had to wait until 10.40pm. It was detailed within the person’s care plan that they did not like to go to bed late. People we spoke to were generally complimentary about the staff. Specific comments included ‘I get on well with all the staff, we have a chit chat,’ ‘all the girls are lovely’ and ‘all staff are very good.’ There were two comments, which were not as positive. These were ‘most staff are good, one or two won’t help you so much, but most are lovely’ and ‘some staff are better than others, say no more.’ One person said ‘you can’t put an old head on young shoulders.’ Within surveys, one person said ‘they are very, very good at listening to you.’ Another person said ‘Some do, mostly [listen to you.]’ We looked at the recruitment documentation of the three most recently employed members of staff. The files contained the required information. There was a photograph, an application form and two written references. Each staff member had been checked against the Protection of Vulnerable Adults register before commencing employment. Criminal Record Bureau (CRB) certificates were in place. We saw that health care matters identified within application forms had been discussed and addressed, as required. Staff told us that they have access to a range of training opportunities. We saw a record of training each member of staff had completed. Documentation Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 28 showed some gaps in mandatory training. Mrs McKeever told us that all training records are now put onto the computer. She said the training records in paper format might not be up to date. Mrs McKeever showed us that staff had completed the training we queried. We advised that if both systems are to be used, information should be routinely updated on the computer and within the staff training file. Mrs McKeever told us that all new staff complete a structured induction programme and then commence their National Vocational Qualification (NVQ.) She said there are consistently over 50 of the staff team with an NVQ. Mrs McKeever told us that staff are currently awaiting infection control training. The head of care is planning to facilitate this with the use of a training pack, which has been recently purchased. Mrs McKeever told us that she has also purchased a DVD regarding ‘nutrition and wellbeing.’ She said updates on catheter care and vision impairment are planned. As stated earlier in this report, we saw that some interactions between staff and people using the service were minimal. We saw a member of staff ask one person if they were well. They did not wait for the person to answer. Within a survey, under the heading ‘what the home does well’ a care manager told us ‘staff take time to get to know clients and appreciate the difficulties of giving up a home. They are good with ‘difficult’ clients and are skilled in diffusing volatile situations.’ They continued to say ‘a lot of experienced staff are employed.’ Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 29 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from an experienced manager. Systems are in place to regularly audit and improve the service provided. The safe keeping of peoples’ personal monies is well managed. Peoples’ wellbeing is promoted through clear health and safety systems yet a review of accidents may minimise further occurrences. EVIDENCE: Within the AQAA, Mrs McKeever told us ‘as the Home Manager I have 7 years experience in working with older people in residential care. I have achieved NVQ level 4 in management and hold a nursing qualification, accredited Dementia training and a first aid at work qualification.’ In addition to this, Mrs McKeever told us that she had recently attended a number of short training Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 30 courses. These included a four day leadership course, end of life care, performance management, care planning and health and safety training. The home has a quality assurance system that is used within all of the homes within the organisation. The system consists of various audits and questionnaires. The organisation’s quality assurance officer did an internal audit of the service in August 2008. Mrs McKeever told us that she had not as yet received the report. Mrs McKeever showed us the evaluation of surveys, which had been undertaken in 2007. These showed general satisfaction yet there were comments about the variety, choice and presentation of meals. In response we saw that a five-week menu had been introduced and some changes to the meals had been made. We saw that there were also some comments about staff being overstretched. As discussed in the staffing section of this report, additional care staff hours have been allocated yet we received similar feedback. Mrs McKeever told us in addition to the quality assurance system, regular resident meetings are held. We saw minutes of the meetings within notice boards around the home. Senior managers visit the home on a monthly basis, as part of regulation 26. Records were in place to demonstrate the areas of discussion, which had taken place. As stated earlier in this report, there have been a high number of thefts within the home. As a result, people are encouraged to store all money and personal valuables securely. Some people told us that they have purchased lockable containers, as a precaution. They told us that Mrs McKeever had kept them informed of the thefts and had given reassurance that everything was being done to address the matter. Mrs McKeever said the main safe had been moved to ensure limited access. Some people had placed small amounts of their personal monies, for the home to hold safely. We looked at the systems for managing this. The cash amounts we checked, corresponded with the balance sheets. Two members of staff signed to demonstrate transactions. We saw that Mrs McKeever regularly audited the systems. She said representatives from the organisation also undertake regular audits. Within the AQAA, it states ‘the home protects the staff, residents and visitors safety and well being by adhering to regulations and legislation, having comprehensive risk assessments, which are regularly reviewed and updated and by ensuring all staff are up to date with manditory training including first aid, food hygeine and moving and handling.’ We saw that the organisation has a range of health and safety policies and procedures. Health and safety audits take place. Additional audits are undertaken as part of senior manager’s monthly visits to the service. The fire log book demonstrated satisfactory testing of the fire alarm systems. Equipment was regularly serviced. We saw that there had been fifteen recorded accidents in August. There were twentyfour accidents in July. Many were not witnessed. We said this was a high level of accidents, which should be investigated. We advised that staff should also document greater detail within the accident book to evidence the circumstances of the accident and how they found the person. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 31 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 30/11/08 2 OP9 13(2) 3 OP9 13(2) The registered person must ensure that care plans are fully completed and in sufficient detail to enable staff have the required information to meet people’s needs effectively. The registered person must carry 30/11/08 out a risk assessment and as a result review practices when medicines are actually administered to people living in the home to make sure that safe procedures are always followed. This is so that the risk of mistakes to people living in the home is reduced to be as low as possible and will help to make sure each person receives the correct amounts of their medicines. 30/11/08 The registered person must ensure that when medication is prescribed for use ‘when required’ or with a variable dose, there is always clear written direction to staff on how to make decisions about administration for each person and medicine in accordance with the Mental Capacity Act 2005. This will help DS0000028140.V369607.R01.S.doc Version 5.2 Cedars (The) Page 33 4 OP9 13(2) 5 OP9 13(2) 6 OP10 12(4)(a) 7 8 OP27 OP27 12(1)(a) 18(1)(a) to make sure there is some consistency for people to receive the correct levels of medication in accordance with their needs and planned actions. The registered person must arrange for medicines needing refrigerated storage to be kept in a locked fridge that can only be accessed by staff authorised to handle medicines. This is to make sure these medicines are stored securely and access by unauthorised persons is prevented. The registered person must upgrade the storage arrangements for controlled drugs to comply with the Misuse of Drugs (Safe Custody) Regulations 1973. This is to make sure these medicines are stored securely and in accordance with the law. The registered person must take measures to ensure that the practices of staff do not impact upon and compromise peoples’ privacy, dignity and wellbeing. The registered person must ensure that peoples’ call bells are answered without delay. The registered person must ensure that staff are sufficiently deployed within areas of the home to meet people’s needs effectively. 30/11/08 31/01/09 23/09/08 23/09/08 23/09/08 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 Good Practice Recommendations DS0000028140.V369607.R01.S.doc Version 5.2 Page 34 Cedars (The) 1 Standard OP9 2 OP9 3 OP9 4 OP12 5 6 OP16 OP33 7 8 OP38 OP38 The registered person should ensure that where creams and ointments are stored in bedrooms, risk assessments are carried out to make sure the arrangements are safe for everyone in the home. The registered person should ensure care plans reflect what choices people were given and have made about how their medicines are administered and their consent to the way in which staff administer their medicines. (This particularly relates to the administration of some medicines during meals times and in a public area.) The registered person should review the recording arrangements for medicines applied externally and consider alternative formats that allow the member of staff who has actually applied the treatment to accurately record this in a consistent way. The registered person should ensure that a review of activity provision is undertaken in line with peoples’ preferred interests. Following this, the amount of hours required to implement such provision should be recalculated. This was identified at the last inspection, yet there was no evidence to demonstrate that it had been addressed. The registered person should ensure that any complaints, which are raised and addressed on a day-to-day basis, are fully documented within the complaint log. The registered person should ensure that systems are devised to enable other stakeholders to give their views as part of the home’s quality assurance system. This was identified at the last inspection, yet there was no evidence to demonstrate that it had been addressed. The registered person should ensure that the number of accidents is investigated and control measures put in place to minimise further occurrences. The registered person should ensure that greater clarity is documented within accident reporting formats. Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Cedars (The) DS0000028140.V369607.R01.S.doc Version 5.2 Page 36 - 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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