Inspection on 17/10/06 for The Cedars (8)

This inspection was carried out on 17th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Cedars (8) 09/10/07

The Cedars (8) 13/01/06

The Cedars (8) 02/08/05

The Cedars (8) 03/02/05

The Cedars (8) 25/08/04

The Cedars (8) 18/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 The Cedars (8) Ashbrooke Sunderland SR2 7TW Lead Inspector Gillian McCabe Key Unannounced Inspection 17th October 2006 10:00 The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars (8) Address Ashbrooke Sunderland SR2 7TW 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) 0191 567 9753 0191 563 7711 lesley.lane@espa.org.uk European Services for People with Autism Limited Mr Francis Damian Evans Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: 8 the Cedars is a detached five-floor house that has been adapted to provide a care service. The home provides personal care for 8 adults who fall within the Autism Spectrum. This house has eight bedrooms and is divided into two units of four. In the downstairs unit the cellar has been converted to provide a bedroom, shower and office. A mezzanine landing contains the dining room and steps, which lead to the kitchen. Both units have their own entrance. Steps lead up to the main entrance for the first unit. The second units separate entrance has a level access but internally stairs lead up to the unit. Neither unit would be suitable for some one with a physical disability. The home is located in Ashbrooke and is walking distance from Villette Road shopping area. There is a range of shops on this busy parade, which include a post office, greengrocer, supermarket, chemist and newsagents. A pleasant park is easy to access. Bus stops can be found on the main road and have routes that go to the city centre and Durham. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day in September 2006 and was a scheduled unannounced inspection. The inspection included a separate look at the pre-inspection questionnaire (completed by the manager) and any comment cards received from residents and/or their relatives. A tour of the building took place, and a sample of residents and staffing records were looked at. Time was spent talking with some members of staff and observing their practice in the home. Time was also spent talking with one resident throughout the day and meeting some other residents who live at No. 8 The Cedars. The judgements made in the report are based on the evidence available to the inspector during the inspection and the pre-inspection questionnaire completed by the manager. What the service does well: No 8 The Cedars is generally a nice and comfortable place to live in and residents appear happy with their surroundings The service continues to encourage residents to particpate in a wide range of activities both in the home and in the local community as part of promoting an independent lifestyle. Staff encourage and support residents as much as possible to particpate in the running of the home. All residents have key workers who encourage residents to participate in daily tasks and routines in the home are centred around the residents. The staff encourage friends and family members to visit the home to see their relatives. Visitors are warmly welcomed. The staff make sure that close contact is kept with healthcare professionals when necessary, staff support residents with visiting healthcare professionals and always seek advice from health care professionals when necessary. This makes sure residents physical and emotional health is taken care of. Good arrangements are in place to make sure residents get their medication when they should. Members of staff have a good understanding of residents’ needs and wishes. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 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. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There have been no new admissions into the home recently. The service considers carefully the needs assessment for each prospective resident before agreeing admission to the home. All resident needs are fully assessed prior to admission. Detailed assessments are in place identifying individual needs, wishes and aspirations. This ensures the home can meet the persons needs fully. EVIDENCE: The home has an admission procedure in place outlining the process prior to admission. Admissions to the home only take place if the service is confident it can meet the needs of the prospective resident. The admissions procedure is available in pictorial format and the manager confirmed that staff will explain the pre admission process with prospective residents prior to their admission. This ensures that any prospective residents fully understand the homes terms and conditions before moving in. As part of case tracking two residents files were looked at and both contained comprehensive assessments. The manager and staff confirmed that the information gathered forms the basis of an individual care or living plan which is subject to regular evaluations. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 9 The home also provides prospective and existing residents with good information about the service provided in the format of a Service User Guide. This information enables any prospective resident to make a choice about whether or not they would like to live at the home. A blank copy of the homes contract known as a ‘licence’ is included in the service user guide however, individual completed licence’s showing details of the homes fees were not available to look at during the inspection. This kind of information is required by regulation 5 of the Care Homes Regulations 2001 and is important to ensure that residents know what they are paying or expected to pay for. The licence is usually signed by the resident or their representative and a representative from the home, demonstrating that all parties are in agreement with the terms and conditions. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents living plans are in place, which reflect individual needs, wishes and aspirations. This ensures that staff always give the correct level and type of support when it is required. Residents are consulted on and participate as much as possible in the running of the home. This helps to promote independence and inclusion. Residents are supported to take some risks within a planned framework as part of an independent lifestyle. Staff follow comprehensive guidelines to ensure the correct level of support is given to minimise any potential risks. EVIDENCE: Two residents files were looked at and both contained very detailed written living plans. The plans identified individual care needs and how they would be met, individual personal goals, risk assessments and details of health related needs. The manager confirmed that annual reviews take place where living The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 11 plans are reviewed and discussed and an action plan is set for the following six months. The manager confirmed that key workers review individual goals in living plans and record progress in residents diaries. This is good practice as it means up to date information is kept reflecting residents changing needs. All Living plans are produced in written words, however not everyone living at the home is able to understand written words and therefore may find their own living plan difficult to understand. Any limitations regarding residents choice are documented in living plans along with the agreement of residents (where possible) or their relatives. Residents do have the potential to challenge staff, which can lead to physical interventions. Living plans detail the action that is needed primarily prior to any physical interventions. Staff have a good knowledge of individual triggers that may lead to behaviours that may challenge and risk assessments are in place to reduce any potential risks. Risk assessments are in place for all residents and the manager confirmed that risk assessments are reviewed periodically. One residents risk assessments did not show evidence of regular review having taken place for some areas of the plan. Comments recorded on one residents risk assessment review were not very descriptive, for example, ‘no change’ was recorded. This wording does not tell the reader how a person is progressing with a particular area. More descriptive language would inform the reader how a person is progressing with a particular area. Staff encourage and support residents as much as possible to participate in the running of the home. All residents have key workers who encourage residents to participate in daily tasks as part of promoting an independent lifestyle. Some tasks carried out may include residents getting support to look after their own bedrooms, carry out laundry tasks and some shopping tasks. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported and assisted to lead active and fulfilling lifestyles by having regular community presence and accessing a range of community facilities. Routines in the home are resident focussed, reviewed regularly and quickly changed to meet individual needs when necessary. Meals provided are healthy, varied and attractively presented in a relaxed and unrushed manner. Plans are in place to incorporate a choice of two evening meals to enable residents to have more choice. EVIDENCE: Residents at No 8 generally prefer to follow the same routines however, staff continue to work very hard and closely with residents to encourage residents to access and take part in appropriate and valued activities. All residents have individual activity plans, some residents enjoy days out shopping, swimming, going to the local theatre and using the Croft centre which offers various activities on a daily basis. Plans are in place for a trip to Blackpool later in the The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 13 year and some residents we getting ready to see Grease at the theatre on the day of the inspection. The manager confirmed that friends and family can visit the home at any reasonable time and are always warmly welcomed however, requests for visits are usually pre-arranged to suit the needs of the people living at No 8. The home has its own cook who prepares meal at No.8. The homes menu’s are planned with residents on a weekly basis and at present do not give a choice of evening meal. However residents are offered alternative meals if they do not like what is on the menu. The manager and cook confirmed that the menu is currently being reviewed to include a choice of meals for each day. Menu choices include Lasagne, salad and garlic bread, Cantonese Chicken with rice, hotdogs with onions and beans on toast. Time was spent talking with manager about producing the homes menus in a format that is easily understood by residents at No. 8 as not all residents are able to understand written words. The manager plans to look at this when completing the menu review. Mealtimes are usually around the same time each day to suit residents needs and residents are supported and encouraged to prepare snacks and beverages throughout the day. One resident was observed being supported to assist staff with making a hot beverage during the afternoon. Staff member was observed giving support in a sensitive manner. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have their personal care needs clearly outlined in the living plans; health care needs are identified and arrangements are in place to ensure they are promoted and met. Robust arrangements are in place to ensure medication is managed well, which promotes the health & well being of residents. EVIDENCE: Comprehensive health profiles are in place giving details of all healthcare professionals involved in each persons health needs. Regular appointments are seen as important and there are systems in place to make sure residents appointments are not missed. Records show that appointments and check ups have been made with professionals such as Chiropodists, Dentist, Optician, Psychologist and G.P. The manager confirmed that close contact is maintained with relevant healthcare professionals when necessary, staff support residents with attending to healthcare needs and actively seek advice from health care professionals where necessary. This ensures residents physical and emotional wellbeing is well monitored. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 15 A sample audit of the homes medication procedures for administration, disposal and storage of medication was carried out. All records looked at were complete and signed appropriately. Sample initials of staff responsible for administration were kept in the medication file and weekly audits are carried out to ensure no mistakes are being made. The manager confirmed that all staff responsible for handling medicines in the home has completed training in Safe Handling Of Medicines, which means all staff have the skills necessary to be fully competent in handling medicines. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 Quality in this out come area is good. This judgement has been made using available evidence including a visit to this service. No 8 The Cedars has robust procedures in place to ensure residents are protected from harm and to address any complaints or concerns about the service. EVIDENCE: No 8 The Cedars has a policy and procedure in place, which set out the values, and principles that underpin the homes approach to the protection of residents. This ensures that all residents are protected from harm. All staff have completed training around MAPPVA procedures, however four staff need to complete refresher training. This training is important as it helps members of staff to keep up to date with the MAPPVA procedures. Staff are aware of whom to contact in the event of an alert and written guidance is displayed in the office for all staff to access. The service is clear when incidents need external input and who to refer the incident to. One investigation has been carried out through MAPPVA procedures since the previous inspection, staff followed guidelines in relation to the procedure and the referral was managed well. The service has a complaints procedure that is up to date and in written and pictorial format. This makes it easier to understand, and to enable anyone associated with the service to make a complaint. No complaints have been made to the service. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. No 8 The Cedars is generally a nice and comfortable place to live in. The home has recently had some refurbishments; however there are still some environmental issues that need attention to ensure the home remains a safe and comfortable place to live. EVIDENCE: The service provides a homely environment. It has a rolling programme to improve the decoration, fixtures and fittings, but occasionally there is slippage of timescales. All residents have their own bedrooms which are personalised and above the average size. There are good sized shared lounges, dining room, bathrooms and toilets. The main kitchen has been refurbished to include new appliances and kitchen units and the walls have been painted. This has been done tastefully and in keeping with the property. Residents are able use the kitchen with staff support to prepare light snacks. A new electric cooker is also due to be fitted. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 18 The laundry facilities are located in the lower floor of the building. Residents are able to use the laundry with staff support to carry out their own laundry tasks, however the laundry area is very small and does not have any ventilation. The laundry area does not have suitable flooring and pipe works in the laundry are exposed. The manager confirmed that consideration is being given to review the area where laundry tasks are carried out to a more accessible area. There are adequate amounts of bathing facilities in the home however the bathroom on floor two of the property in its present condition may not provide a relaxing and comfortable environment for residents to bathe in. The radiator guard is broken, the décor and tiling is dated, and wallpaper is peeling from the wall. The toilet on the third floor also has paper peeling off the walls and pipe works are not boxed in. One bedroom on the lower floor of the property appeared to be damp and had an odour of foist. Time was spent talking with the manager about the ventilation in the room and how to address this matter. A radiator guard in a residents room is broken and in need of urgent repair to ensure safety. Anti topple devices need to be fitted to any freestanding wardrobes in the home. Storage space needs to be found for items such as ironing board, hoover, mops and buckets. The home has the benefit of extensive and well-kept gardens to the rear of the property. Access can be gained from the patio doors off the main lounge or by the kitchen door at the side of the property. The gardens also have the benefit of a large summerhouse which residents use when the weather is fine. One resident was observed carrying out some gardening tasks with support from a member of staff during the inspection. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a good recruitment procedure that clearly defines the process to be followed. The service recognises the importance of training and delivers where possible a programme that meets statutory requirements. EVIDENCE: The homes recruitment process ensures that any person applying for a post with the company have equal opportunities. The recruitment process also involves residents in the process if they wish to do so. Two staff files were looked as part of the inspection and both had evidence of all necessary employment checks being carried out prior to commencement of employment. The service is able to recognise when training is needed and staff members are supported and encouraged to participate in training opportunities in accordance with their own individual training needs. Training is delivered internally and externally. The majority of staff have completed mandatory training. For staff that have not, dates have been planned to complete. Two members of staff have completed and NVQ Level 2 in Care and three members of staff are working towards completion. Two members of staff have The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 20 completed an NVQ Level3 in Care and two members of staff are working towards completing an NVQ Level 4. All staff are clear regarding their role and what is expected from them. Staff spoken with demonstrated confidence in their roles and a good knowledge and understanding of residents needs. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Residents’ benefit from a well run home. The management team are approachable and available for residents and staff so that people living and working in the home are able to feel relaxed about how the home is run. The home has procedures in place for monitoring health and safety Which are generally carried out. EVIDENCE: The current manager has been in post for a number of years and has the required qualifications and experience to run the home and meet its stated aims and objectives. Unfortunately, he is due to leave the home to take up another post. ESPA have made arrangements for a manager currently employed within the company to take over the running of No 8 The Cedars The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 22 with immediate effect. The homes registration certificate needs to be amended to reflect these changes. Quality assurance systems are in place and the operational manager continues to visit the home on a monthly visit to carry out various audits and reports information to CSCI in accordance with regulation 26 of the Care Homes Regulations 2001. The home continues to gather Residents and their relatives’ views as part of the homes quality monitoring system. Questionnaires are sent out on a yearly basis and the information gathered from questionnaires is collated and shared with staff with a view to sharing good practice and highlight any areas of poor practice. The manager confirmed that health & safety checks are carried out as part of the homes quality assurance system, however water temperature records were not available during the inspection. The manager confirmed that water temperatures would be looked at as a matter of priority. Fire records kept in the home are up to date and any accidents that had occurred in the home are recorded appropriately. The home continues to notify CSCI of any incidents or accidents under Regulation 37. The manager confirmed that staff and residents meetings are also held on a regular basis to discuss anything connected to the running of the home. Records of meetings held were not looked at during the inspection. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 2 X The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5(3) Requirement The owners must ensure completed copies of the local authority placing contracts are provided to each service user guide and available in the home. TIMESCALE OF 14/07/06 NOT MET. Individual living plans need to be available in a language or format that can be understood by the resident concerned. Records relating to menus are available in a language or format that can be understood by residents. Records relating to residents risk assessments must be reviewed and up to date. Radiator guards must be in good order. All parts of the home must be kept in good state of repair (Bathroom and Toilet) Ventilation must be provided in all parts of the home, which are used by residents. (Lower floor bedroom) Anti topple devices must be fitted to freestanding furniture in DS0000015774.V304179.R01.S.doc Timescale for action 31/05/07 2. YA6 15 (2) (a) 31/03/07 3. YA17 15 (2) (a) 31/03/07 4. 5. 6. 7. YA19 YA24 YA24 YA24 17 (3) (a) 23 (2) (d) 23(b) 23 (p) 31/12/06 31/12/06 30/06/07 31/12/06 8. YA24 13 (4) (a) 31/12/06 The Cedars (8) Version 5.2 Page 25 the home. 9. YA35 18(1) (c) All staff providing physical interventions must have accredited training and this must be refreshed on a yearly basis. TIMESCALE OF 19/05/06 NOT MET. 19/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA35 Good Practice Recommendations Consideration should be given as to how 50 of care staff will achieve a NVQ Level II by 2005. The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Cedars (8) DS0000015774.V304179.R01.S.doc Version 5.2 Page 27 - 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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