Inspection on 09/09/08 for Cavell Lodge

This is the latest available inspection report for this service, carried out on 9th September 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cavell Lodge 29/05/07

Cavell Lodge 11/05/06

Cavell Lodge 28/09/05

Cavell Lodge 20/05/05

Cavell Lodge 07/03/05

Cavell Lodge 25/10/04

Cavell Lodge 02/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Cavell Lodge 5 Blenheim Chase Leigh On Sea Essex SS9 3BZ Lead Inspector Ann Davey Unannounced Inspection 9th September 2008 08:45 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 Cavell Lodge DS0000015423.V371159.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. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cavell Lodge Address 5 Blenheim Chase Leigh On Sea Essex SS9 3BZ 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) 01702 480660 01702 474316 cavelllodge@btconnect.com Corvell Health Care Limited Manager post vacant Care Home 36 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (36) of places Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Total number of service users for whom personal care is to be provided shall not exceed 36. Personal care can be provided for up to 36 older people over the age of 65 years of age, Personal care can be provided for up to 6 older people who have dementia and are over 65 years of age. 30th October 2007 Date of last inspection Brief Description of the Service: Cavell Lodge provides care and accommodation for thirty-six older residents. Some residents may have care needs associated with dementia. The home is purpose built and provides a good standard of accommodation. There are thirty-two single rooms and two double rooms situated on three floors of the home. All rooms have en-suite facilities. There is access to all floors via a passenger lift. Residents have a choice of several pleasant lounges plus an attractive dining room. The home also has a small quiet lounge, a visitors’ room and a hairdressing salon. There is a large well-maintained garden for residents to use. Off road parking is available. The home is situated reasonably close to a bus route, to local parks and a woodland area. There is a Statement of Purpose and a Service User’s Guide available. A copy of the last inspection report was displayed in the entrance hallway. The weekly charges range from £471.52 - £600.00. The exact fee depends on the type of accommodation available/requested, assessed care needs and the source of funding i.e. private or local authority. There are additional charges for items of a personal nature. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key unannounced site visit that took place over one day. The visit started at 8.45am and finished at 3pm. The manager assisted us throughout the inspection. The last key inspection took place on 30th October 2007. The home had completed and returned their Annual Quality Assurance Assessment (AQAA) to us prior to this inspection. This document gives the home the opportunity of recording what they do well, what they could do better, what has improved in the previous twelve months and their future plans for improving the service. We sent surveys to the manager asking that they be distributed and returned to us so that we could have an understanding of how residents, staff, relatives and health care professionals felt about the care provision within the home. We received ten completed surveys from residents, twelve completed surveys from staff, one completed survey from a health care professional and eight completed surveys from relatives. This was a very good response. Comments from some of these surveys have been included within the report. The day in the home was very pleasant and all staff were co-operative and helpful. A tour of some areas of the home took place. Throughout the inspection, care practices were observed and a random selection of records viewed. We spoke with residents, staff and visitors. A notice was displayed advising any visitors to the home that an inspection was taking place. Two visitors told us that they had seen the notice. All matters relating to the outcome of the inspection were discussed with the manager who took notes so that development work could be started immediately where necessary. What the service does well: This was a very friendly home. Staff knew about residents’ needs. We saw a number of good practices. For example, a member of staff was sensitively encouraging a resident to eat more of their lunch. We saw residents being given choice at lunchtime. Dining tables were attractively laid. The home was clean, bright and airy. The manager’s office area was orderly. Files, records and documentation were easily accessible. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 6 The range of activities and social events provided by the home was good. The home had a team of staff who were well trained. Many of the staff have worked in the home for some time. There are established systems within the home by way of residents/relatives meetings that enable residents to contribute to the day-to-day management of the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 7 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 Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 8 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 and 3 (standard 6 was not inspected as intermediate care is not provided) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care needs are fully assessed before admission to make sure these can be met by the home. EVIDENCE: There was a current Statement of Purpose and Service User’s Guide displayed in the hallway. The home also had an attractive coloured brochure that outlined the services and facilities available in the home. This means that prospective residents are able to read and understand what the home can offer. The pre-admission documentation of the two most recently admitted residents was viewed. Both had a pre-admission assessment document and interim care plan in place. It was clear from the documentation that the residents and their families had been involved in the pre-admission and the admission process. Residents were able to visit the home as part of the pre-admission process. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 9 One resident had come to the home for tea and to meet the other residents prior to any decision being made about admission. We spoke to one resident that had been admitted to the home since the last inspection about their experience of moving in. This resident told us that although they felt anxious about moving in, they quickly felt at ease because everyone was so friendly to them. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive good care but may be at some risk because the care delivered is not underpinned by an established care plan documentation system. EVIDENCE: Five care plans and associated documentation such as risk assessments and accident records were looked at. Within the documentation, there was evidence to support that residents had been consulted about their personal wishes, preferences and the way they wished to be cared for as well as their expectations of the home. Care plans, personal risk assessments, daily reports and healthcare records were in place for all five residents. We could see that individual care needs had been assessed on a monthly basis. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 11 The home had a good recording system in place for all these aspects of care, but the manner in which the information was collated was muddled and not easy to follow. For example, changes in individual residents care needs had been clearly noted in the monthly review document, but the care plan had not been changed to reflect the new assessed needs. The manager acknowledged that some care plans needed to be developed to include all aspects of care such as nutritional needs, otherwise staff may not be aware of what these care needs are. Residents’ personal safety risk assessments were in place. The manager acknowledged that they should be developed as the documentation only recorded what had been put in place i.e. bedrails. Current risk assessments did not identify the risks associated with bedrails being in place or explain the process that led to the decision to provide bedrails. We looked at some entries in the accident book to make sure that the information from any accident had been documented (if appropriate) in the respective residents care plan/daily record. Accident records were well maintained, but on two of the three records we looked at, the information had not been recorded in the daily report or care plan. We also had concern about the detail recorded in the night reports. There was a repetition of the phrase ‘slept well’, when an entry in the accident book recorded that a resident had not slept well due to a fall. The manager had arranged to attend a care-planning course shortly after the inspection. This course is designed for managers. The home had sufficient information to care for residents in a safe way, but the current system means that the information had been recorded in a number of different formats that is not conducive to easy reference or reading for staff. This means that there is a potential risk that staff may not be aware of specific changed care needs or have the right information to make sure that residents are kept safe. We spoke to various members of staff about care practices in the home. Those spoken with had a good understanding of individual resident’s needs. We noted that the rapport between residents and staff was warm, natural and supportive. We stood outside a closed bathroom door where a member of staff was assisting a resident in the bath. The interaction between the member of staff and the resident was friendly and good humoured. The resident was clearly enjoying the experience. We received the following comments from residents within their surveys about their experiences of living in the home ‘care and support is very good’….’if I was not well the staff are always there’….’I’m very happy here’. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 12 The manager reported that the home had a good working relationship with all social and healthcare professionals. We saw entries within the care planning documentation system demonstrating that appropriate assistance is provided when required. The following comment was received from a health care professional within their survey ‘it is apparent on entering (the home) that there is a welcoming feeling combined with a cheerful, caring attitude amongst staff’. We looked at the medication administration, storage and recording systems and sampled various aspects for compliance. Each resident had a MAR (medication administration record) sheet in place. There were no unexplained gaps. Routine day-to day-medicines were neatly stored in a metal trolley or the designated fridge (for eye drops and liquid medicines that require refrigeration). The medicines trolley is normally housed in the medication room on the 2nd floor. During the morning we saw the unattended locked trolley left in the dining area. The manager understood that if the trolley is to be left in this area, it must be secured to the wall. There was no overstocking of medicines. We saw records to support that staff had been trained to administer medicines in a safe way. The home had a PRN (a medicine to be administered as/when necessary) procedure in place. The manager was in the process of developing individual resident’s PRN protocols. The manager told us that these protocols would be in place by the end of September. Cavell Lodge DS0000015423.V371159.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a good diet provision and a good social activity programme. EVIDENCE: The manager reported that all residents had contact with either their families, neighbours or friends. During the day there was a steady stream of visitors. One visitor told us that the home was ‘warm and friendly’, whilst another visitor told us ‘it’s like home from home’. The home had a comfortable visitor’s room on the ground floor should privacy be needed during a visit. The home facilitated a two weekly Church of England communion service. The manager reported that the local church was very supportive to the home. In addition, the manager demonstrated other contacts the home had with other local churches. From our conversations with residents and from the comments in their surveys, all indicated that within reason they were able to exercise choice and control over their personal lives within the home. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 14 One resident reported ‘they always asked me about things…..this is my home’. Another resident acknowledged that there had to be some routines in the home, but indicated that they were acceptable. We observed that some residents were reading newspapers. One resident reported that ‘oh, yes I have my paper every day, the other resident reported…..’they always make sure my paper is here’. Residents’ were able to benefit from a good and varied activities/social programme. The September programme was displayed in the home and recorded 26 planned events/activities for September. For example, mobile shop visit, quiz night, pub lunch, visit to the local theatre, an external entertainer and a sing a long. During the afternoon of our visit, there was a singer booked. All residents and staff were enjoying this event. The home had it’s own mini bus which meant that small groups of residents could be taken out together. In addition, the mini bus was also used to take individual residents for hospital and GP appointments. Residents were very complimentary about the activities and social events on offer. One visitor reported ‘there’s always something going on here, or they’re going somewhere or other’…….’we’re always invited to come along as well’. In July, residents were supported by staff and relatives in holding a fete in the home’s grounds. There were photos in the hallway that demonstrated that the event was a tremendous success. The home is registered to provide care for residents that have care needs associated with dementia. As the manager develops the activities/social programme, consideration must be given to ensure that suitable activities and occupation are made available to meet their needs. The daily menu was displayed. Records supported that there was a choice of main dish available at lunchtime. For example, lamb chop/liver and bacon and vegetables or gammon bacon/salmon. At 10am on the morning of our visit, some residents were still in the dining room having breakfast. We saw trays being collected from residents’ bedrooms where it had been requested that they be provided with breakfast in their bedrooms. The dining tables were attractively laid at lunchtime and the food looked appetising. We saw staff sensitively assisting residents with their food. Mid morning tea and coffee was nicely served in china cups and saucers and a selection of biscuits was available. Residents commented that what we saw was quite normal and were complementary about the food. Cavell Lodge DS0000015423.V371159.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for in an environment where they are comfortable to raise concerns and know that these would be dealt with appropriately. EVIDENCE: The complaints procedure was clearly displayed in the hallway. The home had an established complaints recording system. The manager acknowledged that the system should be more structured to show the progress of any complaint investigation as there was no clear tracking process in place. We asked several residents if they would feel comfortable about raising any concern with either the manager or a member of staff. All those spoken with indicated that they would feel comfortable and felt confident that matters would be taken seriously. When asked about if residents knew what to do if there was cause for concern, the following comments were made in their surveys ‘I would go to the office and see the manager’….’of course I would tell someone, I know it would get sorted out’. We saw records to demonstrate that training had been provided for staff to ensure residents were protected and the measures that would be taken should poor practice be suspected. We asked three members of staff about their understanding of the procedure they would follow. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 16 All three understood the term ‘protecting vulnerable adults’ and explained to us the correct procedure should they suspect poor practice. They also told us about the home’s whistle blowing policy and procedures. A safeguarding vulnerable adults from harm incident is currently being investigated by Southend Borough Council (safeguarding team). The incident is in connection with poor care practice. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 17 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, 23, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and clean home. EVIDENCE: The home was furnished and decorated to a very good standard. The lounge and dining areas were comfortable. Residents’ bedrooms were personalised and homely. Bathrooms and toilet areas were functional. The laundry, kitchen and sluice area were clean and tidy. The garden area was well maintained and attractive. Corridors, stairways and communal areas were clear and free from hazards. The manager’s office, the administrator’s office, the senior carers’ office, the visitors room and the staff room were decorated and furnished in a style suitable for their function. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 18 We spoke to two residents who told us that they like to spend some of the day in their respective bedrooms because ‘it’s nice’ and ‘I’ve got everything I need in here’. Both commented that although by choice they stay in their rooms, they do not feel isolated because ‘somebody is always around….’I never miss out on my drinks you know’. Some residents had their own private telephone line. The home is registered to provide care for residents who may have care needs associated with dementia. The manager showed us some pictorial signage notices that are due to be displayed around the home to help some residents become more orientated and promote independence. In the bathroom on the ground floor, we noticed a holder on the wall containing a roll of plastic bags. The manager must ensure that measures are in place to prevent residents coming to harm. Residents who have care needs associated with their dementia may use this area unsupervised. There were no unpleasant odours in the home. Apart from the unsupervised plastic bags, we saw no other areas or aspects of the home that caused us concern for the safety of residents. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A team of well recruited and trained staff look after residents. EVIDENCE: A current and clear staff rota was available. The rota showed us that there was a minimum of six care staff (including two seniors) on duty in the morning, five care staff (including 1 senior) on duty in the afternoon/evening and 3 care staff (including 1 senior) on awake duty at night. The home also employs administration, domestic, housekeeping, cooking and maintenance staff. The manager reported that there were no staff vacancies and the core group of staff had been working in the home for some time. This means that residents were benefiting from being cared for by a team of established staff. Staff had been provided with a Staff Handbook. Staff told us that there were regular supervision and team meetings. We saw records to support this. We saw records of two staff that had been recruited to the home since the last inspection. Records were in good order. Records reflected that four senior members of staff had achieved NVQ level 3 and ten members of care staff had achieved NVQ level 2. Further NVQ training is planned. Records supported that the home had a sound and established induction and training programme in place. We spoke with the NVQ Assessor who was visiting the home on the day. The assessor commented on the good standard of training provided for staff. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 20 The manager showed us the home’s Training Needs Analysis document that clearly showed the names of staff that have undertaken training and those where training is required or due. There was also a Workforce Development Plan that provided a clear audit of the home’s training programme. Our findings supported the view that residents were being cared for by a team of staff that had been well recruited, properly induction and trained to a good standard. Staff we spoke with knew about the care needs of residents. We saw supportive and friendly interaction between staff and residents. Staff were friendly and knowledgeable about their respective roles and responsibilities. Residents commented to us ‘staff are nice’….’they’re kind’….’they’re good to me’….they’re always so busy and I have to wait sometimes, but I’ve no complaint’. One visitor said ‘they do want they can, they’re so busy sometimes’, another visitor told us ‘they are so good here’. Within their surveys staff told us ‘ my induction covered all aspects that I needed to know to do my job’….I have regular supervision’….’I have training which is relevant to my role’….’there is always enough staff to look after residents’. Staff during the visit commented to us that they had good training opportunities and liked working in the home. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for in an environment where their care needs are managed well. EVIDENCE: Since the last inspection, the manager had completed NVQ level 4 training and as is due to commence a two year part-time Leadership and Management in Care course at the end of September. Staff reported that they felt supported by the manager and liked the open leadership and management style. One visitor commented ‘she’s a good manager’, another said ‘she’s got things sorted out here and I know X is in good hands’. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 22 We experienced no difficulty in locating the documentation and reports requested as part of the visit. The manager’s office that accommodated the majority of the records was orderly and demonstrated good management skills. The home had a generic environmental and a safe working practices assessment folder in place. We saw infection control and safety notices around the home. The home had a current fire risk assessment in place. The manager was monitoring compliance on a monthly basis. There were records to demonstrate that fire drills, checks on fire fighting equipment/emergency lighting and hot water temperatures had been carried out on a regular basis. There was a maintenance book that demonstrated that all maintenance issues had addressed regularly and effectively. We saw records to support that regular resident meetings had taken place. We have been are kept informed about notifiable matters (for example, falls that require medical attention) that are required through Regulation 37 reports. We also saw the records of the Regulation 26 reports that require the owner of the home to complete monthly. This record demonstrates that the owner knows about the day-to-day management of the home and is satisfied that compliance with the Care Homes Regulations is being achieved. The home was looking after residents’ personal monies if requested. The system for these financial transactions had a good audit trail. We sampled a couple of service/maintenance documents and found them to be current. For example, the passenger lift and the moving and lifting hoists had been serviced since the last inspection. Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 3 3 X 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 Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 24 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 Every resident must have a detailed current plan of care in place. This document must include all aspects of care/health as detailed in the minimum care standards (No 3), and contain/make reference to appropriate risk assessments Without adequate current documentation, staff may not be aware of assessed care/health needs or how they should be met. Timescale for action 30/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Cavell Lodge DS0000015423.V371159.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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