Care Home: The Cedars

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What the care home does well Assessments of people`s needs are undertaken and include details of risks, to ensure people`s needs can be met. People receive care in a way that respects their privacy and dignity. A relative said: "The home feels very comfortable and relaxed when you enter the building; it is the sort of place you could call home. Staff clearly know their residents very well and have a lovely rapport with them, nothing is too much trouble. The staff`s total dedication never ceases to amaze me". Staff said: ". We tend to people`s needs and preferences promoting independence where possible". "I really enjoy working here; it is very homely and comfortable. Residents are well cared for and seem very happy. Staff integrate very well with residents, socially as well as in a caring way. Families seem very comfortable to approach staff and all staff respect and treat families in a welcome manner". Training for staff is provided to ensure that care is given by people who have relevant knowledge of how to give care safely. Staff said "I find management very supportive and they listen to my ideas and encourage training". Audits on how the home runs are carried out by the manager and other staff, to ensure the quality of the service is monitored and any shortfalls identified are dealt with thoroughly. What has improved since the last inspection? Care plans now include enough detail to guide staff and they are developed with each individual person or their relative or representative as soon as possible after admission. Recruitment procedures are robust and all necessary information is gained to make sure that people are recruited are suitable to work in the care industry. The hairdresser makes sure that there are no trip hazards caused by trailing wires, to protect people`s health and safety. Management hold regular staff meetings to gain the staffs views and act on any issues raised. Staff now sit by the side of people they are helping to eat at meal times to improve the experience for people who need to be assisted. What the care home could do better: Interim care plans that are discontinued should have the date that these were discontinued recorded so that the records are easier to follow and reflect people`s current needs. Risk assessments for the use of bed rails should be more detailed to include the risk of entrapment and should be signed by the person or their chosen representative. The choice of food available at meal times should be displayed so that people can read what is available to eat. Criminal Record Bureau checks should be repeated periodically for all staff to make sure people continue to be protected. The laundry floor must be repaired so that thorough cleaning of this area can take place, to maintain infection control. CARE HOMES FOR OLDER PEOPLE The Cedars Church Side Methley Leeds West Yorkshire LS26 9BH Lead Inspector Denise Rouse Key Unannounced Inspection 14th April 2009 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Cedars DS0000001621.V374724.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 DS0000001621.V374724.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars Address Church Side Methley Leeds West Yorkshire LS26 9BH 01977 512 993 01977 604088 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) The Cedars Partnership Kathleen B Morgan Care Home 39 Category(ies) of Dementia - over 65 years of age (39), Old age, registration, with number not falling within any other category (39) of places The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th April 2007 Brief Description of the Service: The Cedars, located in the village of Methley, near to Castleford, is classed as being in the Leeds area. The home can accommodate up to thirty-nine older people, including up to 39 people diagnosed with Dementia. The home does not provide nursing care. Local healthcare teams give healthcare support to the home. Accommodation is provided in two buildings, the main house and the Cottage. The main house has rooms for twenty-six residents. An enclosed courtyard provides a safe area for residents to walk and sit in the fresh air. Bedrooms are situated over four floors and some of these are in a modern extension. Access to the upper floors is provided by a passenger lift and a stair lift in addition to the stairs. There are eighteen single and four shared bedrooms, two of these with en-suite facilities. The Cottage has nine single rooms, one having en-suite facilities. One of the two double rooms also has en-suite facilities. Access to all rooms is via the staircase. The home is situated in large attractive gardens with parking. A large enclosed courtyard provides secure outdoor space for people with dementia to use safely and independently. The weekly fees charged on the day of the site visit ranged from £415.32 to £450.00. Information is available to people to help them make an informed decision about if the home is the right place for them. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The accumulated evidence used in this report has included: • A review of the information held on the home’s file since its last key inspection. Information submitted by the registered provider in the Annual Quality Assurance Assessment. Surveys received from nine people living at the home, two health care professional and three staff. An unannounced visit to the home which lasted five hours thirty minutes undertaken by one inspector, which included a full tour of the premises. Evidence was gained by direct observation during the site visit; which involved talking with people living at the home, visitors, the management team and other members of staff. Inspection of records, including care profiles, medication administration records, staff files and some of the home’s policies and procedures. What the service does well: Assessments of people’s needs are undertaken and include details of risks, to ensure people’s needs can be met. People receive care in a way that respects their privacy and dignity. A relative said: “The home feels very comfortable and relaxed when you enter the building; it is the sort of place you could call home. Staff clearly know their residents very well and have a lovely rapport with them, nothing is too much trouble. The staff’s total dedication never ceases to amaze me”. Staff said: “. We tend to people’s needs and preferences promoting independence where possible”. “I really enjoy working here; it is very homely and comfortable. Residents are well cared for and seem very happy. Staff integrate very well with residents, socially as well as in a caring way. Families seem very comfortable to approach staff and all staff respect and treat families in a welcome manner”. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 6 Training for staff is provided to ensure that care is given by people who have relevant knowledge of how to give care safely. Staff said “I find management very supportive and they listen to my ideas and encourage training”. Audits on how the home runs are carried out by the manager and other staff, to ensure the quality of the service is monitored and any shortfalls identified are dealt with thoroughly. What has improved since the last inspection? What they could do better: Interim care plans that are discontinued should have the date that these were discontinued recorded so that the records are easier to follow and reflect people’s current needs. Risk assessments for the use of bed rails should be more detailed to include the risk of entrapment and should be signed by the person or their chosen representative. The choice of food available at meal times should be displayed so that people can read what is available to eat. Criminal Record Bureau checks should be repeated periodically for all staff to make sure people continue to be protected. The laundry floor must be repaired so that thorough cleaning of this area can take place, to maintain infection control. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 7 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 DS0000001621.V374724.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 DS0000001621.V374724.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): Standard 2 (6 not applicable). People who use this service experience good quality outcome in this area. People are assessed prior to being accepted into the home so that their needs are known and can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pre-admission assessments are undertaken by experienced staff who find out what individual needs people have, including their social and mental health needs. Information from care managers and discharging hospitals is also gained to make sure the home knows people’s full needs. Admissions are not made to the home if people’s needs cannot be met. Information is available to people in the statement of purpose, service user guide and last inspection report. This ensures that people are well informed about what the home has to offer them so that an informed choice can be made. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 10 Prospective residents are invited to visit the home to look round with their family or chosen representative. They can have lunch or stay for the day or a trial period. Staff are available to answer their questions and they can visit as many times as they like. Surveys received indicated that all nine people who completed a survey felt they receive enough information about the home to make an informed choice about if this home was the right place for them. Comments received included “All the staff gave very full details of care and made us most welcome” and “Someone came to see me and told me about this place”. Some relatives spoken with said “We looked at lots of homes, we stuck to our guns and got mum in here its nice and homely it smells of nice food and nothing else. The manager assessed mum and as soon as there was a space she moved in and settled straight away”. Intermediate care is not provided. The Cedars DS0000001621.V374724.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. People who use this service experience good quality outcome in this area. People’s health care needs are met and medication policies and procedure’s protect people living in the home. However risk assessment regarding the use of bed rails should be more detailed to help protect people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who use the service have care plans and risk assessments in place these are reviewed monthly or as the person’s needs change. People with special needs relating to their mobility, nutrition and memory have individual care plans and risk assessments in place. However risk assessments for the use of bed rails were very basic and these should be reviewed to provide more detail and include the risk of entrapment. They should also be signed by the person or their chosen representative, to make sure all parties have been informed of the potential risks of using this equipment. Care plans being introduced are more person centred focusing on people’s strengths and how staff can support them to achieve their goals and they have The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 12 become more detailed. It was discussed that interim care plans that are discontinued should have the date that these were discontinued recorded so that the records are easier to follow. The manager holds care reviews with people living in the home and their representatives every year. These reviews are documented to make sure that all parties are fully informed and agree with the package of care the home is providing. Nine people living at the home completed a survey, all nine said they always received the care and support they needed. Comments received included: “The care staff give one hundred percent support at all times”. And “The care and support of the staff at The Cedars is exceptional”. Health care professionals are asked for help and advice to enhance the care that people receive. People can go to the local surgery supported by staff or have the general practitioner visit them at the home. People said in their surveys that they received the medical support that they needed. Comments included: “They always get the doctor for me when I am ill”. Specialist equipment is available to ensure that people’s individual and special health care needs are met. People follow their chosen routines. Staff help and support people with poor memory in a sensitive way to promote their dignity. Medication systems inspected on both units protect people living in the home. At present no one is able to self medicate however the manager stated that people would be assessed and helped to self medicate if they were capable and safe to do so. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 13 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. People who use this service experience good quality outcome in this area. People’s social needs are known by staff and are being met, a nutritious diet is provided, However menus are not displayed for people to choose from. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A variety of activities are available including singers and entertainers visiting the home to perform. Film presentation’s, bingo and quizzes. Gentle exercises are also provided. Motivation and Co also visit to provide games and group activities. There is an activity co- coordinator provided 10 hours per week and the home are looking to take on a second person and increase the amount of activities that are on offer to people. These co-ordinators will be trained in activity skills, at present the activity co-ordinator is a carer and so understands people’s need very well. People said they could join in with activities if they wished to or relax in the lounges or their bedrooms if they did not want to take part. On the afternoon of the site visit there was a bus trip out for some people living in the home to Butterfly World. People’s relatives are invited to events and on outings so that it is a real family affair. Birthdays and special events are celebrated and special The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 14 Italian, French Spanish and Chinese evening events have been held as well as Summer and Autumn Fayres. Bonfire night and Valentine’s Day were celebrated and at Easter their were Easter Bonnets and Easter eggs for people to enjoy. There has also been a trip to Bridlington and a trip to Temple Newsom for tea and cakes. At Christmas everyone gets a visit from Father Christmas and all get a present which is provided by the fundraising undertaken by the home during the year. The local school choir comes in to sing carols and there is a Buffet put on which people’s relatives and representatives are invited to attend, this makes sure that the manager and staff are looking after people’s extended family as well as those people who live at the home. This is seen as being incredibly important by the management and staff at the home who pride themselves in including everyone. People’s religious needs are known, local clergy visit the home regularly to provide Holy Communion and to see people privately. People are escorted to local events at the church “Tea, God and Me”, if they wish to attend. A hairdresser attends the home weekly as well as a chiropodist as required. People are taken for local walks round the Church and over the cricket field and to local shops or pubs. Fish and chip evenings are held. There is a yearly programme of activities organised. March and April’s programme of activities were available for people so they could plan to attend events if they wished. People with dementia are treated the same as other people at the home, the staff know their needs well and make sure that they get activities which suit their needs such as reminiscence memory boxes which have been created at the home to help people talk about their childhood, work or family life. Open visiting occurs. People can go out with their family and friends, this helps to promote their independence. The kitchen was inspected, the systems for preparing food are satisfactory and lunch was enjoyed by people in their bedrooms or in the dining areas. People could eat where they wished. On both units people were helped and supported to eat by staff who sat at the person’s side. Meal times are unhurried to allow people time to enjoy their food. The menu was not displayed on both units. The choices available should be displayed so people can be reminded what is available to them. This was discussed with the manager who said that menus would be displayed. The chef knew who required special diets and food was home cooked so that it smelt inviting and helped people to maintain their appetite. One person commented “I really enjoy the food here”. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 15 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. People who use this service experience good quality outcome in this area. People are protected from abuse, complaints are dealt with. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed. Complaints would be investigated and the person informed of the outcome. The manager operates an open door policy; anyone one can see her to make their views known at any time. People surveyed said they knew how to make a complaint and issues raised would be dealt with. They knew who to speak to if they were not happy. One person commented “The manager is always happy to listen and support us as are all the staff”. A safeguarding policy is in place, there have been no safeguarding issues. Staff spoken with knew what to do if an allegation of abuse occurred. Ongoing training and information relating to the whistle blowing procedure has been given to all staff and issues would be brought to the manager’s attention for appropriate action to be taken. This helps to make sure that people are be protected from abuse. Checks are undertaken to ensure new staff are suitable to work in the care industry. However some staff who had worked at the home for a number of years should have their Criminal Record Bureau checks repeated to make sure that people continue to be adequatly protected. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 16 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 & 26. People who use this service experience good quality outcome in this area. People live in a home that is well maintained so that it is nice for people to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is maintained and decorated to make sure it is homely and inviting for people to live in. There are plans to make the main house and the Cottage connected in the future. There is a secure door entry system in place in the main house and the Cottage to make sure that unauthorised entry to the home cannot be gained, and people cannot wander out of the home without staff being aware helps to protect people. There is signage to help people to locate the toilets to help people to find these facilities. In some bathrooms in the main house and in the Cottage general The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 17 cleaning products were found for staff to use, because some people who live at the home may not understand what these items were for. These products were removed for safe storage. Lockable cupboards are to be fitted to store these products securely to help protect people who live in the home. This was already being organised by the handyman at the time of the site visit. There are lounge and dining areas available on the ground floor of both units. There is a passenger lift in the main house going up to the third floor and a stair lift to gain access to the bedrooms on the fourth floor, which helps people access all areas of the home. One person commented “The home always smells fresh and looks clean”. Bedrooms are personalised and have hand basins available for people to use, a few bedrooms also have en suite toilets. There are some double bedrooms which have screens between the beds to make sure people’s privacy and dignity is maintained. There are gardens available for people to enjoy, these are well maintained. There is a central secure courtyard garden so people can go outside if they wish without being able to wander away from the home. The grounds are suitable for disabled access, and garden furniture is available for people to sit on. The laundry facilities inspected are adequate for the home and soiled linen is bagged and washed separately. Industrial washers and dryers are in place with sluice cycles. The laundry floor has five areas where the lino had worn away and the hardboard floor is exposed. The floor covering must be replaced to make sure that the floor can be thoroughly cleaned to help prevent cross contamination occurring. There are plans to create a new laundry which will greatly enhance the laundry facilities that are available in the home. Hand wash facilities are available throughout the home to help maintain infection control. People surveyed said they were happy with the facilities the home had to offer. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 18 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. People who use this service experience good quality outcome in this area. People are looked after by adequate numbers of well-trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken with were friendly approachable and positive about the role they played in the home. Staffing level are adequate to ensure people get the care they require. One person said “The staff are extremely friendly and helpful”. Relatives commented “We feel safe and happy with all the care and support The Cedars give to XXXX. We have no worries; our relative’s needs are all met. It’s a home from home and we wouldn’t have XXXX moved anywhere else”. Staff update their training to ensure their health and safety is protected and that of the people living in the home. Staff are recruited using thorough methods and there is an equal opportunities policy in place so that recruitment is fair for all applicants. New staff have a period of induction and one member of staff said in their staff survey “I was given all relevant information during my induction”. A health care professional said in their survey “I have found that the skills and experience of all members of staff to be of an excellent standard. Those members of staff who are new to the care sector are supported and trained by the more senior staff. The nature of my work takes me to many homes in the care sector across the whole of West Yorkshire. In my experience I have found The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 19 the Cedars to be one of the best homes that I visit. I have always found it to be a pleasure to train the staff as they are always so willing to learn”. The home has over 50 of care staff that have achieved a National Vocational Qualification at level 2 or 3. This helps to make sure that people are looked after by well-trained staff. A member of staff said in their survey “We are given regular training which is relevant to our job and helps us to keep up to date with the new ways of working. Our courses help us to understand and meet the needs of the different individuals we care for and their different needs and beliefs. We have regular support and appraisals with our manager; this is where I discuss how I am working and where I would need further training and support”. Staff meetings are held to gain the views of people working in the home. Any issues raised are looked at by management acted upon. Staff spoken with said they felt the company put the residents at the centre of what they do and they help and support staff. Other comments received were “Care staff have a professional approach”. And “The staff respond to people’s different needs”. And “There is genuine warmth of care from the staff”. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 20 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 and 38. People who use this service experience good quality outcome in this area. People benefit from a well managed home, their health and safety is protected and people’s views are gained and listened to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been at the home for a long time, she is experienced and approachable. There is a deputy manager to help and support her. The operations manager visits the home regularly to make sure that the home is operating effectively. The management team are always looking at how they can improve the services they have to offer to people. The manager works as part of the staff team two days a week this helps her understand people’s needs and monitor what is happening in the home. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 21 Quality assurance procedures are in place. Audits are carried out, these look at all departments as well as asking the views of people living at the home. The management team addresses any issues that are raised. Policies and procedures are in place. Staff and resident and relative meetings are held regularly. The company also send out surveys to people living in the home to gain their views about the service. Personal allowance accounts are not provided for people living in the home, some balances were checked and were found to be correct. Receipts are kept for all transactions. This helps to protect people from financial abuse. Health and safety checks and regular maintenance is undertaken to make sure that the home is a safe and pleasant place for people to live. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 22 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 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 1 STAFFING Standard No Score 27 3 28 3 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 The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 23 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 OP26 Regulation 23 (2) (b) Requirement The laundry floor must be repaired so that effective cleaning of this area can take place, to maintain infection control. Timescale for action 14/06/09 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 OP7 Good Practice Recommendations Interim care plans that are discontinued should have the date that these were discontinued recorded so that the records are easier to follow. Risk assessments for the use of bed rails should be more detailed to include the risk of entrapment and should be signed by the person or their chosen representative. 2 OP15 Menus should be displayed so that people can be reminded DS0000001621.V374724.R01.S.doc Version 5.2 Page 24 The Cedars 3 OP18 what food is available for them at each mealtime. Criminal Record Bureau checks should be repeated periodically for all staff to make sure people continue to be adequatly protected. The Cedars DS0000001621.V374724.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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