Inspection on 23/10/07 for The Cedars and Larches Care Home

This inspection was carried out on 23rd October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Cedars and Larches Care Home 20/11/06

The Cedars and Larches Care Home 28/02/06

The Cedars and Larches Care Home 18/07/05

The Cedars and Larches Care Home 27/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Cedars and Larches Care Home 16 Queens Drive Ilkeston Derbyshire DE7 5GR Lead Inspector Steve Smith Unannounced Inspection 23rd October 2007 09:30 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 The Cedars and Larches Care Home DS0000002129.V351832.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. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars and Larches Care Home Address 16 Queens Drive Ilkeston Derbyshire DE7 5GR 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) 0115 9440166 Exceler Healthcare Services Limited Mrs Janina Ann Wright Care Home 69 Category(ies) of Old age, not falling within any other category registration, with number (69) of places The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The Cedars and Larches Care Home is registered to provide personal care with nursing to male and female service users who fall within the following categories: Old age, not falling within any other category (OP) 69 may be admitted to The Cedars and Larches Care Home The Cedars and Larches Care Home may accommodate the person of category LP/PD named in the variation letter dated 3rd August 2005. The Cedars and Larches Care Home may accommodate the person of category DE(E) named in variation application V34857. The maximum number of persons to be accommodated at the Cedars and Larches Care Home is 69. 20th November 2006 Date of last inspection Brief Description of the Service: The Cedars and Larches is registered to provide nursing and personal care for up to 69 Residents over the age of 65. The Home is situated close to the centre of the town of Ilkeston, in a quiet but accessible location. The Home is on one site, but in two distinct wings, all but joined in the middle. One wing is called The Cedars and provides residential care, and The Larches provides nursing care. Each wing is very similar, although The Larches has wider corridors, due to providing a nursing service. Each wing provides a main lounge and dining area on the ground floor, with smaller lounges on the first floor. The Home also has one passenger lift and staircase in each wing, providing access to the first floor facilities. In the main, the Home provides single bedrooms, although a small number of double bedrooms are available. No ensuite facilities are provided, but there are sufficient toilet and hygiene facilities available throughout the Home. All bedrooms are equipped with a link to the call system. Residents are encouraged to personalise their bedrooms with small items of furniture and mementoes, if they so wish. Support services are in place, with a choice of General Practitioners, and chiropody, dental, optician and other services arranged as appropriate. A visiting hairdressing service is provided. An Activities Coordinator is employed, throughout five days of the week. There is a gardened area beside the home, which has been designed to be The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 5 accessible to all Residents. The Home has open visiting arrangements. The charges made for a room at The Cedars and Larches range from £308.00 to £498.00 a week, dependent on the size of room, the facilities provided, whether the room is a double or single room, and whether residential or nursing care is required. Details of previous inspection reports can be found on the Commission for Social Care Inspection’s website: www.csci.org.uk The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of 7.5 hours. Discussion was held with two Residents, and the records of four Residents were ‘case tracked’. Discussion was also held with the Manager and with two members of the care staff. A number of records were examined, and the bedrooms of four Residents were examined, and all public areas of the Home were looked at. The Commission’s Annual Quality Assurance Assessment questionnaire, was not available at the time of this visit to the Home. The Commission’s Residents questionnaire was also not available at the time of this visit to the Home. What the service does well: What has improved since the last inspection? Since the last inspection, in November 2006, the Registered Providers have updated the Residents Guide in line with the legal changes that came into force during 2006. Improvements had also been made to the administration of medication. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 7 All staff had been appropriately trained to meet the needs of Residents at all times, and the Manager was found to now maintain a copy of verbally passed on complaints as well as written complaints. 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 summary of this inspection report can be made available in other formats on request. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 8 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 The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 9 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): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a detailed statement of purpose for the Home together with a Resident’s Guide, which was available in each Residents bedroom. The Guide was well completed, and included information from Residents on what life was like in the Home. The Residents Guide also contained information on how contact could be made with the Commission, the local Social Services Dept and the local Health Authority. The records of four Residents were examined during this inspection and a copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, was found in each file. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 10 When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. The Manager also assessed all Residents sponsored by Social Services Depts. If the Residents were self-funding from the outset, the Manager completed her own summary of needs, which were also seen during the inspection. Standard 6 does not apply to this Home. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met, as demonstrated within care plans, and medication was administered appropriately to meet Residents needs. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. That was, their name and date of birth, their preferred name, their next of kin, their GP, and their Care Manager. Records of the Manager’s initial assessment of each Resident were found in each file, together with completed Individual Plans of care for each Resident. All these records were found to be up to date and of a good standard. Records of the risk assessment on each Resident were also available. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 12 However, the Manager had not provided required information for those Residents suffering with dementia. As a result, in two of the four files examined, there were no records of the Resident’s possible limitations of choice, freedom and decision making, despite these Residents suffering with dementia. The Manager was found to be recording the 6 monthly reviews of care of each Resident, which was shared with local Social Services Depts who undertook formal reviews of care on an annual basis. All of the files were easy to read and good entries had been made by the nursing staff. The Manager had reviewed the records of each Resident at regular intervals. The files were well organised, with different sections, although a confidential records section was not found in any of the files examined. In one of the Resident’s files a member of staff had asked other staff to ‘monitor’ the Resident, concerning a particular problem for the Resident. However, this was only done the following day, and no other member of staff referred to the request to monitor. Staff were observed talking and assisting Residents with meals in both The Larches and Cedars section of the Home. This was seen to be done very positively, with a relaxed atmosphere, which was enjoyed by the Residents. Nursing staff were appropriately maintaining the records of Residents health needs, and care staff were appropriately caring for Residents personal and oral care needs. All medication and the method of distributing it to Residents was examined, and a good system was found to be in use. However, the following issue needed to be addressed: The Medication Administration Records (MAR), in the Larches part of the Home, were found to start on differing dates, making signing the record of the distribution of medication unclear. It was recommended to the Manager that all MAR sheets should start on the same date each month. Discussion was held with Residents about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘The staff are always bothered to make sure I am comfortable, they are all very nice’ - ‘Staff always do things my way. I was scared at home, and I made The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 13 a good decision to move to this Home.’ Staff were observed to be attentive and caring at all times. Discussions were also held with Staff, and very positive ways were described of assisting Residents within the Home. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, and Residents were given a wholesome and appealing diet in pleasant surroundings, that enhanced Residents well being. EVIDENCE: Residents were asked about the activities provided in the Home. Those spoken with said that the Home had an Activities Coordinator, who was described as being very good, doing group activities and individual activities. Staff were asked about this and they confirmed that the Activities Coordinator visited the home approximately 5 days each week, and worked across both parts of the Home. Activities described by both Residents and staff included such things as bingo, skittles, dominoes, cake decorating, biscuit making, working with potted plants, preparing for special events such as Christmas, and going into the local town on shopping trips, or outings. Residents said that they decided when they got up and went to bed – ‘Yes, I decide when I get up and go to bed.’ Another Residents said that ‘I bath every day, and staff turn me two hourly during the day and the night.’ The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 15 Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘Oh yes, I always see my daughter in private.’ The staff spoken with also said that relatives could visit at anytime. It was said that Residents could chose where they wanted to see their relatives, in one of the lounges, or in the Resident’s bedroom. Residents had a mixed response when asked how staff entered their bedrooms. One said that ‘Staff knock and wait for me to say ‘come in’ before doing so.’ But another said that ‘Staff always knock, but always just walk in.’ Residents were able to say that the Home provided good meals and that a choice was available at breakfast, dinnertime and teatime meals – ‘A choice is offered at all meals,’ Staff also confirmed this. The staff said that drinks and snacks were always provided between meals, and that mealtimes were never rushed, which was witnessed during this visit to the Home. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 16 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): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: One Resident said that if she complained – ‘I would tell carers, and if I didn’t get satisfaction I would go up the ranks until I got to (the Manager).’ Another Resident said that she would tell the person in charge that particular day. Residents were found to be very comfortable with this procedure, and their rights to complain, if necessary. The Commission had not received any notice of complaint since the last visit to the Home, in November 2006. Since that visit, the Manager had recorded three verbal complaints, and she said that all complaints were reviewed by the Home’s head office. At this visit to the Home the three complaints were examined and a satisfactory system was found to operate. Good procedures were seen for both written and verbal complaints. The Registered Provider’s complaints procedure detailed that all complaints would be responded to by the Registered Provider or Manager within at least 28 days. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 17 The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. The Manager said that a copy of the Public Interest Disclosure Act of 1998, and of the Dept of Health’s policy called ‘No Secrets’ were available in the Home. The Manager also confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Providers ensured that all staff understood physical and verbal aggression by Residents. The Manager said that a policy was available to staff stating that they could not benefit from Residents wills, which was also understood by the staff, with whom discussions were held. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 18 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): Standards 19, 20, 21, 22, 23, 24, 25, & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the public areas of the Home, and included the four bedrooms of the Residents whose care was reviewed at the time of this visit. The Home was attractively decorated throughout, and the lounges and dining rooms were most pleasant to sit in, and were provided with appropriate items for the Residents. The bedrooms seen provided sufficient space and provision for each Resident. The Registered Providers had provided appropriate furnishings in all locations seen during this visit. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 19 Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. A call system was also available throughout the Home. All bedroom doors were provided with locks, which Residents could chose to use. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Care staffing was provided to meet the needs of Residents, and appropriate recruitment practices were always followed when recruiting new staff, so that Residents welfare was always safeguarded. EVIDENCE: A satisfactory level of staffing was found to be provided in the Home to meet the needs of Residents. At the time of this visit it was found that 50 of care staff had a qualification of at least NVQ level 2 in Care, and a further 9 staff where currently undertaking the course. The records of two new staff employed during the past 12 months were examined to see whether the Manager had obtained all relevant information about them. It was found that almost all information had been obtained. However, the history of employment of one of the staff had only been taken over the previous 10 years, and not back to when they had left school. This was needed to allow the Manager to check whether the potential member of staff had worked in care in the past, to allow an additional reference to be obtained. All other information was found to be satisfactory. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 21 The Manager said that new staff would be provided with induction and foundation training, which was confirmed by staff. She also said that all care staff were provided with at least three paid days training a year. The records of some of this training was seen. All staff also had an individual training and development assessment and profile. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35, 36 & 38. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were in place to ensure that Residents care was maintained at a positive standard. EVIDENCE: The Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management and a Nursing qualification. The records of the monthly ‘inspections’ of the Home, carried out by a senior manager, were examined and found to be in good order. The Manager was able to show the annual development plan for the Home, completed in conjunction with a senior manager, that reflected the aims and outcomes for Residents. Surveys had been undertaken of Residents opinions of the operation of the Home, and these had been published. The Manager The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 23 also said that she discussed with Residents the operation of the Home at Residents meetings, the minutes of which were posted on one of the Home’s notice boards. She also stated that she and the staff would be able to demonstrate the Home’s commitment to lifelong learning and development of each Resident in the Home, which was confirmed by staff spoken with during the visit to the Home. The opinions of Residents families and friends or of GPs and District Nurses were obtained on how well they thought the Home was achieving goals for Residents, during reviews of the care provided for each Resident. These were again published and posted on a notice board of the Home. The Manager stated that a computer record was kept of all Residents saving held by the Home. This total amount of money was kept in a non-profit making bank account and only the paper transactions were maintained in the Home. It was therefore not possible to check savings held against actual money kept in the Home. Two staff members were asked about the supervision they received from the Manager or other senior staff in the Home. One said that this was done on approximately a 6 monthly basis, when her own needs and the needs of the Residents were discussed. The other member of staff said that she had not had any supervision, although she knew that other staff received it. The training required by the Regulations was examined. This showed that Moving and Handling training and Food Hygiene training had been provided for all appropriate staff in the Home. Only three staff were found to be in need of Fire Safety training, and 5 staff needed Infection Control training. However, the information on First Aid training was not available to the Manager at the time of this visit to the home. All staff spoken with said that they had received training in all 5 areas, although one said that she was awaiting training in First Aid. In addition to the above areas of training the Manager said that training was offered in Customer Care, Pressure Care, Care Planning, Challenging Behaviour, Dementia Awareness, and the Safe Use of Bedrails. The Registered Providers had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Manager was able to show that the Registered Providers had provide risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff. The Registered Providers had also provided a written statement of the policy, organisation and arrangements for maintaining those safe working practices. Finally, the Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 24 government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 25 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 17(1)(a) & Sch. 3, 3(q) Requirement The Manager must ensure that each Resident, or their representative, has the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome must be recorded in each Resident’s records, at least at the time of the formal 6 monthly review of care. (This issue is outstanding from the inspection report dated 20 November 2006) The Manager must ensure, when appointing new staff, that all the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004, are obtained. Of two staff’s records examined, it was found that a full history of employment had not been obtained, dating back to when the member of staff had left school. If the person had worked in any form of care before, an additional reference would need to be obtained. DS0000002129.V351832.R01.S.doc Timescale for action 20/12/07 2. OP29 19 & Sch 2 20/12/07 The Cedars and Larches Care Home Version 5.2 Page 27 3. 4. OP36 OP38 18(2)(a) 13(3) & 18(1)(c) Supervision must be provided for all care staff. Mandatory training must be provide for the 3 staff requiring Fire Safety training, and the 5 members of staff requiring Infection Control training. When the details of the staff requiring training in First Aid is recovered they must receive this training within the time scale shown on this form. 20/12/07 28/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP7 No. 1. Good Practice Recommendations Each Resident’s file should contain a ‘confidential’ section. This section should be used for records made by staff that the Resident should not see and for information passed to the Home by professionals to which the Resident had not been made party. When staff use the Resident’s record of events to ask other staff to carry out tasks, such as ‘Please observe’ or ‘Please monitor’, the task should be addressed on each entry following until the staff member requesting the task signs it off as no longer needed. 2. 3. OP9 OP12 Medication Administration Record sheets should all start on the same date. Staff should be made aware of those Residents who should be encouraged, following staff knocking on their bedroom door, to invite staff into their bedrooms and those Residents who can no longer do this. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 28 4 OP36 The Manager should arrange for all care staff to receive supervision at least 6 times a year; once every 2 months. The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Cedars and Larches Care Home DS0000002129.V351832.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!