Care Home: The Cedars

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What the care home does well The Cedars continues to provide a very pleasant relaxed atmosphere. People living in the home said they were happy with the care provided. All residents spoken to say that the food was always of a good standard with a choice for each meal. Staff spoken to say that it was a happy relaxed atmosphere to work in. They were observed to have a cheerful rapport with the people living in the home. The impression of the home is that it is a friendly comfortable and safe place to live and the staff are respectful and caring. The activities provide a regular, varied and stimulating programme to suit individual preferences. The environment is well maintained and provides a good range of comfortable, pleasant rooms. There is a rolling programme of re-decoration and upgrades in place. The gardens have been fully restored creating a pleasant patio and gardens on both sides of the home, each of which have seating and shady areas, and which are assessable, provide colour and interesting outlooks. What has improved since the last inspection? The ethos of the home is more person centred and policies and procedures are being reviewed and updated. What the care home could do better: Prepare a written service user plan to form the basis of the care to be delivered and health and welfare needs met. Prepare a written service user plan to form the basis of the care to be delivered and health and welfare needs met. Arrange for the safe storage and recording of controlled drugs by use of an appropriate CD cabinet properly affixed and a CD book. Provide lockable facilities for residents to keep money and medication in their bedrooms where residents are self-medicating and manage their own money. The provider must complete Reg 26 inspections and write a report each month. Carry out risk assessments and take appropriate actions on hot water outlets to reduce the risk of scalding to residents. Consider using standardised questioning and recording at interviews so comparisons can be made between candidates. CARE HOMES FOR OLDER PEOPLE The Cedars 8 Clevedon Road Weston Super Mare North Somerset BS23 1DG Lead Inspector Andrew Pollard Unannounced Inspection 22nd August 2008 09:45 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 DS0000071692.V367829.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 DS0000071692.V367829.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cedars Address 8 Clevedon Road Weston Super Mare North Somerset BS23 1DG 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) 01934 629773 mail@cedarsresidentialhome.co.uk The Cedars (Weston) Limited Mrs Mandy Elizabeth Timmins Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 28. Date of last inspection Brief Description of the Service: The Cedars is registered to provide personal care for 28 people aged 65 or over. Accommodation is provided on two floors in single rooms, all of which have en-suite facilities. There is a passenger lift. The home is situated close to the sea front at Weston-Super-Mare and within an easy reach of amenities. There are attractive, sheltered gardens to the rear of the home. Current fees are £395 per week The Cedars DS0000071692.V367829.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. We came to this quality rating at the last key inspection. This unannounced inspection took place over one day in the presence of the Manager Mrs M Timmins. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the regulations of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. An Annual Quality Assurance Assessment (AQAA) was completed by the homeowner and forwarded to the Commission for Social Care Inspection (CSCI). This inspection focused on outcomes for the individual’s. This is evidenced through inspecting key standards and surveying and checking records and documents. Individuals who live at the home, visitors and staff were spoken to. Reference was made to the last report. Five surveys were received from residents and one from a member of staff prior to this report being written. All comments were positive no complaints were made A tour of the premises was made. Inspection feedback was given and the visit was concluded. What the service does well: The Cedars continues to provide a very pleasant relaxed atmosphere. People living in the home said they were happy with the care provided. All residents spoken to say that the food was always of a good standard with a choice for each meal. Staff spoken to say that it was a happy relaxed atmosphere to work in. They were observed to have a cheerful rapport with the people living in the home. The impression of the home is that it is a friendly comfortable and safe place to live and the staff are respectful and caring. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 6 The activities provide a regular, varied and stimulating programme to suit individual preferences. The environment is well maintained and provides a good range of comfortable, pleasant rooms. There is a rolling programme of re-decoration and upgrades in place. The gardens have been fully restored creating a pleasant patio and gardens on both sides of the home, each of which have seating and shady areas, and which are assessable, provide colour and interesting outlooks. What has improved since the last inspection? What they could do better: Prepare a written service user plan to form the basis of the care to be delivered and health and welfare needs met. Prepare a written service user plan to form the basis of the care to be delivered and health and welfare needs met. Arrange for the safe storage and recording of controlled drugs by use of an appropriate CD cabinet properly affixed and a CD book. Provide lockable facilities for residents to keep money and medication in their bedrooms where residents are self-medicating and manage their own money. The provider must complete Reg 26 inspections and write a report each month. Carry out risk assessments and take appropriate actions on hot water outlets to reduce the risk of scalding to residents. Consider using standardised questioning and recording at interviews so comparisons can be made between candidates. The Cedars DS0000071692.V367829.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 DS0000071692.V367829.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 DS0000071692.V367829.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): 1,3,5, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and their families are given relevant information in written or verbal form about the home. Contracts and terms and conditions of services are provided to all clients. The assessment procedure is clear and a thorough assessment of prospective residents needs is carried out. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 10 EVIDENCE: A statement of purpose and a home guide is made available at the initial stage of enquiry to prospective residents/families. This provides useful information of the services available and includes the terms and conditions. The statement of purpose is being expanded to fully reflect the range of needs and admission criteria that the home can accommodate. The manager confirmed that an admission would only be made if the home could meet the needs of the person wanting to move in. The documentation used by staff from initial enquiry to day of admission contain prompts to ensure prospective residents are given all the relevant information and support required. People are offered the chance to visit the home prior to admission and or by a relative on their behalf. Trial visits and meals are offered. The manager demonstrated a clear understanding of the admission process for individuals to the home. For those residents who are funded by the local authority the home had in place a care management assessment in order to make a decision on whether the home and the skills of the staff team are able to meet the individual’s needs. A review takes place after one month’s placement at the home, at this meeting the residents and their representatives are present and make their views known, these are recorded and appropriate action is taken. The Cedars DS0000071692.V367829.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): 7,8,9,10,11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s health care needs are met, and they are treated with respect. Medication is well managed for the benefit of residents but self-storage arrangements should be better. The service user plan does not fully reflect a detailed and personalised record of the care to be provided for each resident. EVIDENCE: Each resident is referred to a GP on admission to the home; residents are registered with a local surgery or retain their existing GP. The doctors carry out visits on request, as do District Nurses. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 12 Evidence from the care files and discussions with residents and staff showed that residents have visits from their GPs, dentist, opticians and other health professionals. Where they wish visit theses services in the community the staff offer assistance. General Practitioner (GP) and Para-medical visits and their outcomes are documented. The manager fully demonstrated a clear understanding of the admission process for individuals to the home. The home has an admission procedure and pre-admission assessments are covering activities of daily living, health needs and personal history. Senior carers and key workers are involved with creating documentation. For those residents who are funded by the local authority the home had in place a care management assessment / care plan. A general summery of the care to be given is written out, however, what is lacking are properly formatted service user plans giving full person centred detail. It is recommended that the person centred ethos of the staff’s approach be used in the development of service user plans/ care plans. The manager states that it is intended that each resident has a brief biography written and person centred assessments where their wishes, likes and dislikes are put at the centre of the care provided and regular evaluations/reviews take place. It is intended that people’s health and social needs including, psychological, emotional, and cultural needs will be detailed to demonstrates that the home takes a holistic approach to the provision of care. This was supported in discussion with residents and staff. At present there are no specific night care plans, however the manager intends to introduce such. The night staff are going to be delegated responsibility for writing person centred night care plans. As yet formal end of life plans have not been written, however, basic information is collected regarding this where possible. The manager is seeking information about symptom control and formal end of life training at the Hospice, possibly using the Liverpool Care Pathway. Daily diary entries are made. Risk assessments were in place with detailed information to ensure safe procedures for example, manual handling, and the correct use of aids. Residents spoken with stated that they are well cared for and Comments included, “I am happy with the care I get”, “staff are excellent”, and “staff help me when I ask them”. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 13 Medication procedures and practices in the Home were reviewed, and for routine drugs the Home operates a safe system of storage, administration and recording of medication. Disposal arrangements are in line with current legislation, however we discussed the importance of recording disposals at the time they are taken out of use and the reason for disposing of them. The home has controlled drugs (patches) but no CD cupboard or CD book. The manager is seeking advice of the pharmacist as the area where the drug trolley is located is to be changed when the dining room is upgraded and a CD cupboard will be installed at the new trolley location. Two residents are able to self medicate but at present have no lockable storage in their rooms, the manager has made a request to the provider for this provision that can also be used to keep money and valuables. The Cedars DS0000071692.V367829.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): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home treats people as individuals, and routines are built around needs and preferences rather than staff convenience. A range of social and recreational activities is arranged that seek to enhance the quality of life for the residents. Resident’s families are involved and informed of issues related to their relatives and are able to maintain close contact with families and friends. The food is of a high standard offers choice and provides a balanced diet for residents. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 15 EVIDENCE: People spoken to, weekly activity posters and photographic evidence in the home showed that a varied and meaningful programme of activities is provided. Evidence from the previous report stated. The main ethos in the home is that people living there are given the chance to take control of their daily routines wherever this is practicable; people are given choice in most aspects of their lives. People returning surveys and spoken to said that they could exercise choice and control over their own lives and felt that the home was run for their benefit. Staff spoken to were very conscious of enabling people living in the home to continue to make personal choices. Regular entertainment is provided in the afternoons including singers, guests, games, carpet skittles, beetle drives and beauty therapy. Special events are arranged throughout the year and residents and visitors are invited to attend. Special events are arranged such as birthday parties, visiting theatres, summer fetes and themed events throughout the year. The residents have free use of a community mini bus or coach for trips and outings. A programme of events is set out in a displayed weekly programme. Individuals have records of their social and activity choices and record of participation in their files. On the day of the inspection people in the home were attending Anglican Holy Communion. A priest and members of the Mormon Church also make regular visits. People living in the home are asked on a daily basis about their meal preferences. This is then conveyed to the cook. If a person does not want either choice another option can be offered. There is a good range of hot and cold options offered at each meal. The menus continue to contain a variety of well-balanced meals that reflect the preferences of the people living in the home. No one has any special cultural dietary requirement at present. Residents surveyed and spoken with all praised the quality of the food. People also confirmed that their relatives and friends are made welcome in the home. During the inspection relatives were seen to come and go throughout the day. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 16 The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are robust and comprehensive policies in place to protect residents investigate complaints or manage allegations of abuse. There are good arrangements in place for staff training and awareness of Adults Protection matters. EVIDENCE: The home’s complaints policy and procedure have a clear timeline and set out the action to be taken in event of a complaint. A copy is displayed in the home and other copies are available on request or contained in the Service user Guide. The policy is being amended to include reference to Social Services. The manager maintains a full record of complaints; none have been received since the last inspection The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 18 The home has written procedures for adult protection, whistle blowing and the management of challenging behaviour. The Local Authority ‘No Secrets’ document was available. The manager is a trainer and actively promotes staff training and education in adult protection issues on induction and by regular updates from an external provider. A number of staff are undertaking the National Vocational Qualification in care award, and a component of the award addresses issues around the topic of safeguarding adults from abuse. Staff spoken to showed an awareness of the policies and procedures in place to safeguard vulnerable adults. People surveyed and spoken to say they knew how to make a complaint if they needed to, they all felt they could approach the staff at anytime with any concern and it would be taken seriously. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and well-maintained environment and the standard of furnishing and décor is good to the benefit of residents. The bedrooms and communal rooms and facilities are suitable and well presented for their purpose and meet the resident’s needs. The standard of cleanliness is high. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Home is situated in Weston near the seafront and a short distance from the town centre and nearby to bus stops. This helps ensure residents can be a part of the community. The home is a two-storey building, and residents have access to all areas there is a lift servicing the upper floor. The Cedars is homely with a variety of communal areas, which are well furnished so that people living in the home can sit in small groups. The furnishings and lighting are domestic in style whilst providing light to read by. The furniture and fittings are of good standard and communal areas are well decorated. There are plans to upgrade and decorate the dining room following a water leak recently. Bedrooms are ensuite and communal bathrooms and toilets were clean, and were well stocked with hand towels and soap to help minimize risk from cross infection in the Home. A programme of re-decoration is being followed as and when rooms become available. People spoken to say that they liked their rooms and had bought in their own furniture and possessions, which made them, feel more at home. Residents were observed sitting in the lounges and going into their rooms, looking relaxed and comfortable in their environment. Residents’ comments confirmed that the home is and clean and they are happy with the environment. Residents have access to newly restored garden areas that are pleasantly laid out with flowerbeds and patio areas. The home showed a generally good standard of housekeeping and cleaning and no offensive odours were apparent. The only areas that required attention was some food debris under two seat cushions and some high dusting required. The home has an infection control policy and guidelines. Protective clothing was being used; staff have personal bottles of hand sanitizer, which they keep on their person. All staff change out of their uniform before leaving the premises this is good practice. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and records are in generally good order to protect residents. The home is well staffed with appropriately trained and experienced staff for the number and needs of the residents. Good progress is being made training care staff for the benefit of residents. EVIDENCE: Staffing rotas showed that the home is adequately staffed for the needs of the people living in the home. Extra staff can be used at peak times or for activities. The manager is on duty during the day Monday to Friday plus sundry additional hours. There are four care staff on duty in the morning and 3 care staff in the afternoon. At night there are two waking care staff. There are adequate numbers of catering and ancillary staff on duty. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 22 Staff interactions with residents were heard to be cheerful and caring. Each resident has a key worker to support them with the manager being involved with the overall monitoring of individual care. It was clear from surveys and discussions that staff have developed relationships with individuals and support people appropriately. The staff indicated that the team is very stable with high morale. Residents’ spoken with agreed that staff were always available when they needed them and always listened and acted upon what the residents had to say. Staff that were observed to be supporting and caring for the residents, they were patient and encouraged residents to make choices. The care staff at the home are encouraged to undertake National Vocational Qualification (NVQ) training and the home currently has a good percentage of the staff holding an NVQ qualification of level 2 or 3 and other staff either attending the training or planning to start. All new staff receive an eight day Induction programme following the Common Induction standards. Training records showed that all mandatory training had been attended including, fire safety, food hygiene, first aid, load handling, medication and adult protection in addition relevant learning is being undertaken related to the residents needs. The last inspection found the recruitment procedure was based on equal opportunities, was robust and proper procedures and employment records were kept. The files examined confirmed safe recruitment practices being followed. However we discussed the interview notes, which were not based on standardised questioning so comparisons between candidates could not clearly be made. The manager intends to improve the recording to make information The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run taking into account the views and wishes of the residents and relatives. There are good arrangements in place to maintain and service the equipment and facilities in the home and protect the health and safety of residents and staff. The staff supervision and appraisal arrangements are good to enhance care delivery to residents. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 24 EVIDENCE: Mrs M Timmins the registered Manager has previous experience in the community managing a Domiciliary Care Agency and has also completed the Registered Managers Award. Consideration is being given to the creation of a deputy manager post. There are two senior carers in post both with higher level NVQ training. The home is part of a group and HR, invoicing and payroll are managed by head office. No regulation 26 reports are being written by the provider at present. All staff have an annual appraisal, which identifies learning needs and they receive 6 weekly supervision, which follows a standard format. Staff can also express their ideas or concerns at staff meetings. The Annual Quality Assurance Assessment (AQAA) returned to the CSCI was clear about the homes commitment to maintaining an environment that recognises the diverse needs of the people in their care and developing a service that will meet those needs on an individual basis. The Cedars take seriously comments made by people living in the home and their relatives. Quality assurance questionnaires have been forwarded to relatives and people living in the home. The manager said they are collating the evidence and producing an action plan based on the comments made. In future it is intended to carry out thematic surveys focusing on different aspects of the home. Comments were said to be very complimentary with both relatives and people living in the home very pleased with the standard of care they received. The home has a Health and Safety policy and audits and relevant training takes place. Generic and individual risk assessments are in place and kept under review. Manual handling risk assessments are completed for all residents, these had been completed and areas of potential risk and how residents would be supported were recorded. Health and safety records showed that relevant inspections and maintenance has been carried out at the required intervals for the fire alarms and equipment, gas and electrical services, hoists and stair lift. At present there are no formal risk assessments of hot water outlets to reduce the risk of scalding residents. Baths and showers do not have mixing valves in place. The kitchens have been awarded a 4 star rating by the Local Authority. A review of the fire logbook showed all tests, training and drills were being carried out to the Avon and Somerset Fire Brigade guidelines. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 25 All bedroom doors that remain open, on request of the resident have automatic door closers that are activated when the fire alarm sounds. The policy relating to the management of money/valuables is being properly implemented and up to date records maintained. At present residents do not have lockable facilities to keep valuable or money in their rooms. The manager has requested the providers to supply such. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 26 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 X 3 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 30/09/08 2. OP9 13.2 3. 4. OP37 OP38 26 13.4 Prepare a written service user plan to form the basis of the care to be delivered and health and welfare needs met. Arrange for the safe storage and 15/10/08 recording of controlled drugs by use of an appropriate CD cabinet properly affixed and a CD book. The provider must complete Reg 30/09/08 26 inspections and write a report each month. Carry out risk assessments and 30/09/08 take appropriate actions on hot water outlets to reduce the risk of scalding to residents. The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 28 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. 2. Refer to Standard OP18 Good Practice Recommendations Provide lockable facilities for residents to keep money and medication in bedrooms where residents are selfmedicating and manage their own money. Consider using standardised questioning and recording at interviews so comparisons can be made between candidates. OP29 The Cedars DS0000071692.V367829.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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