Inspection on 16/05/05 for Cedar Lawn Nursing Home

This inspection was carried out on 16th May 2005.

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

The inspector 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

Cedar Lawn Nursing Home 22/03/07

Cedar Lawn Nursing Home 31/10/05

Cedar Lawn Nursing Home 02/12/04

Cedar Lawn Nursing Home 06/07/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cedar Lawn Woodley Court Braishfield Romsey Hampshire, SO51 7PA Lead Inspector Tim Inkson Unannounced 16th May 2005 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 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. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cedar Lawn Address Woodley Court Braishfield Romsey Hampshire SO51 7PA 01794 523300 01794 518820 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sentinel Healthcare Ltd Mrs Sheila Hewitt CRH 30 Category(ies) of PD Physical disability - 6 registration, with number TI(E) Terminally ill - 30 of places PD(E) Physical dis - over 65 - 30 TI Terminally ill - 6 OP Old age - 30 Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Only six service users in the categories of PD and TI between the ages of 50 64 shall be accommodated at any one time. Date of last inspection 02.12.2004 Brief Description of the Service: Cedar Lawn Nursing Home is one of four homes in Hampshire owned by Sentinel Health Care Limited. The home is located in a quiet close on the outskirts of Romsey, a small market town. A former manor house converted for use as a care home, the building has been tastefully refurbished and extended and is set in pleasant and well-maintained gardens. The bedroom accommodation is on 2 floors and comprises 22 single and 4 shared rooms; 22 rooms have en-suite facilities. The home benefits from a lounge with dining area, in addition to a sun lounge. Other facilities include a passenger lift, assisted baths, a laundry service and full board. The home is registered for thirty service users over sixty-five and for six service users between the ages of fifty and sixty five in the categories of terminal illness and physical disability. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was the first of at least two visits that must be made to the home between April 2005 and March 2006. It started at 08:55 and finished at approximately 15:40 hours. During the inspection records and documents were examined, working practices and the main meal of the day observed and an opportunity was taken to speak to residents (11), staff (6) and visitors/relatives (2). Senior staff were available throughout the inspection and able to provide advice and information. The operations director for Sentinel Health Ltd was available towards the end of the inspection for discussion about issues identified during the visit. At the time of the inspection there were 25 residents accommodated, of these 22 were female and 3 were male and their ages ranged from 66 to x 102 years. What the service does well: The management of the home was, open, efficient and responsive and a major factor that ensured that living and working in the home was a pleasant and enjoyable experience. Consequently residents well being and contentment was evident in their comments about life in the home as exemplified by the concise views of one who said: “We are well looked after, its kept clean, the atmosphere is fine and the girls are wonderful”. There were friendly and relaxed relationships between staff and residents and visitors. The meals/food provided by the home, the welcome visitors received and the home’s activities programme were viewed positively by all concerned. The standard of care was good with the staff able to meet the needs of residents and ensure that the fundamental principles that underpin good care were promoted. Residents felt valued as individuals and also that their opinions were sought on aspects of life in the home. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 and 5 There were good admission procedures in place that included providing potential service users with information about the home and assessment of their care and nursing needs before they moved into the home. Potential service users were also able to visit the home and/or have a trial stay before deciding whether to live there permanently. EVIDENCE: The home had a Statement of Purpose and a Service Users Guide that included all the necessary information that is required by the Care Homes Regulations 2001. This ensured that potential and existing service users knew among other things, how the home was run and the facilities, care and support that was provided by the home. Copies of the guide were observed in the entrance hall to the home and also in service users bedrooms. Service users and visiting relatives said that before they moved into the home they received written details about the home and that they were able to visit Cedar Lawn in order to ascertain whether it was suitable for them. In addition they said that before they moved in that someone from the home had visited them to see what help they needed. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 9 • “Matron came to see me in hospital and I told her about all my ailments, I was given a very informative book all about the home” A sample of the records of 4 service users was examined including those of an individual who had very recently been admitted to the home. They indicated that comprehensive assessments of the needs of potential service users were made before they moved into the home. More comprehensive assessments of service users needs were completed immediately after they were admitted to the home. Nationally recognised tools/methods were used and these included assessments of a range of risks associated with among other things; falling; mobility; and skin integrity. Local authority community care assessments and care plans were available where an individual had been admitted to the home through care management arrangements. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 There were good systems in place to ensure that the social and health care needs of service users were met and their privacy and dignity was promoted. EVIDENCE: The care plans and related records of 4 service users were examined. Plans of care were detailed and set out the action staff had to take and any equipment that was necessary to meet the assessed needs of service users. There was documentary evidence that service users and /or representatives were involved in the development of the care plans and that they were reviewed regularly. The plans referred to the principles that underpin social care e.g. • “Maintain dignity at all times”. • “Able to select what clothes she wears”. Service users said that the help and care they received was in accordance with their agreed plans and where equipment (e.g. Hearing aid; wheelchair, Zimmer frame), or provision of specific help (e.g. assistance with feeding), was required this was observed to be in place or being provided. • “They look after me very well” • “The staff help me quite a bit, bathing and dressing and I cannot stand without help”. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 11 • “ I get all the help I need” Staff were able to describe the contents of care plans and the details of the specific care and help that service users required. One visitor said, “the staff know all the idiosyncrasies of the residents”. Records, observation and discussion with service users indicated that the home promoted the health care needs of individuals. Documents used for recording contact with health care professionals included details of referrals to specialists for investigation, advice and treatment. A visiting general practitioner was very complimentary about the home and staff and said that the home used the services of the primary health care team appropriately. Service users said that doctors routinely visited the home every two weeks from a local practice. In addition that the home arranged visits to specialists, clinics etc, when necessary and that other regular health care checks and treatments were arranged for them. • “I see the doctor when I need to and the chiropodist about every six weeks” • “Doctors come, chiropodists come regularly and we all had our eyes tested recently”. • “The physio says that she does not have to come and see me again. I am waiting for a hearing aid and matron has it in hand”. A range of recognised methods of assessing service users health needs and for identifying appropriate interventions that may be required included consideration of; skin integrity; continence; mobility and nutrition. Equipment or action plans were in place where necessary e.g. air mattress; hoist; provision of continence products; soft diet and help and encouragement with feeding. There were detailed and specific care plans in place for the management of wounds and there was evidence that these were monitored and reviewed appropriately. All service users said that the staff respected their privacy and dignity and staff were observed knocking on bedroom doors and waiting for a response before entering. “They are always polite and they use the screen in my bedroom – they always knock on the door”. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 There were a good variety of activities and events organised from which service users could benefit. Good links were maintained with the community and visitors were encouraged and made welcome. The meals in the home were good, providing variety, choice and catering for special dietary needs. EVIDENCE: The home employed an activities organiser 5-days a week and had the use of a mini bus used to take service users out. There was evidence from notices and information around the home and what service users said that providing stimulating entertainment for service users was a priority in the home. At the time of the inspection a group of service users was going out on a trip to a local pub for lunch. The records of service users that were examined included details about their leisure interests. • “We have a nice entertainments manager who organises trips out, we play scrabble and musical bingo, and have entertainers come in, singers and musicians” • “I join in all the activities” There were televisions in both of the home’s lounges and also music centre in the larger of the home’s two lounge areas and in the other which was used as a “quiet lounge” there was a selection of books and board games. • “We have a lovely library, a good pick of books” Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 13 Some service users spoken to said that they preferred to remain in their rooms and one said that she was not a “good mixer” and was an avid reader and enjoyed listening to her radio. The activities organiser said that service users who were to frail to join activities and those who were bedfast were seen individually. If they were able to communicate she would spend time chatting with them and also providing hand massages and manicures. Service users and visitors said that the home’s visiting arrangements were flexible and that visitors were made welcome. • “My daughter lives locally and comes every other day, my son lives in X and comes at weekends when he can, there are no restrictions” (service user) • “You can have visitors whenever you like” (service user) • “They are very supportive I am always offered a drink and lunch” (visitor) All service users and visitors without exception said that the food provided by the home was good. They confirmed that they had 3 meals a day and could have drinks and snacks at other times. In addition that they were able to choose from a range of options that they were notified about beforehand and that were available each day. They also said that specific dietary requirements were catered for. There was evidence of the ready availability of fresh fruit and the provision of jugs of fluids in communal areas and bedrooms. There was documentary evidence that was confirmed by service users that regular meetings were held with service users at which matters including the home’s menus and catering arrangements were discussed. Comments about meals included the following: • “The food is good, the chef is a great friend of mine” (service user) • “The food is quite good actually, I always like what I have” (service user) • “Its very reasonable, we have a good assortment and there is plenty of it. They ask us what we want from a choice, so if we don’t like it its our fault” (service user) • “It is very good, there is plenty and what I particularly like is that there is always a good selection of vegetables. I always have a glass of wine with my lunch” (service user) • “It is excellent I have eaten here. They are always wiling to change it and he has all the items are pureed separately. He said they were the best sausages he had tasted for years” (visitor) Information about the needs of service users with specific dietary requirements was readily available in the kitchen e.g. diabetic; soft; chopped up; small; medium: etc. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Arrangement for protecting service users and responding to their concerns were satisfactory. EVIDENCE: The home’s complaints procedure was readily accessible in the Service Users Guide, a copy of which was available in every bedroom and in the entrance hall to the home. Service users said that they were confident about taking up any concerns with the home’s manager. One service user said that she would speak to her relatives about any complaints. A record of complaints made to the home was kept and there had been 7 made since the last inspection of the home on 2nd December 2004. The records set out the agreed action necessary to resolve the matter and the outcome. No complaints had been made about the home to the CSCI in the last 12 months. The home had a number of written detailed policies and procedures concerned with adult protection and related matters. These included: • The Local Authority’s Protection Procedures • Aggression • Confidentiality • Control and Restraint • Prevention of Abuse • Procedure for dealing with resident’s money • Bequests and Wills Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 15 There was documentary evidence that all the home’s staff had undertaken training in abuse. This was confirmed in conversations with staff. It was apparent from these discussions that they all knew the appropriate action to be taken if they suspected or knew that abuse was occurring in the home. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 and 26 The home provided a comfortable, clean and safe standard of accommodation to meet service users needs. EVIDENCE: The communal areas of the home comprises two lounge/dining rooms and as such there is an element of choice and different areas where separate activities can take place. One is a large room overlooking the grounds at the front of the building. The other situated at the rear of the home is a smaller room that was regarded as the “quiet lounge”. • “I was able to use the small day room with my family for my birthday” The outside areas comprised a sizable area of lawn at the front of the building and two level courtyard areas one to the side and one at the rear of the home and all outside areas were easily accessible for service users. At the time of the inspection the construction of a new conservatory attached to the larger of the two communal rooms was nearing completion. This should considerably enhance the facilities of the home. The furnishings and décor of the communal rooms was domestic in character and in good repair. All service users said that the communal areas were comfortable and clean. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 17 Service users and visitors said that the home was kept clean and a member of staff was observed diligently cleaning some areas of the home during the inspection visit. There were no offensive odours in the building at the time of the inspection and comments about the cleanliness included: “My room is thoroughly cleaned by 2 people every day” (service user) “What impressed me most was the atmosphere and cleanliness … no strange smells” (visitor). Staff were observed using protective clothing appropriately and it was apparent from records and discussion with staff that “health and safety” and “infection control” were training courses that all staff were required to attend. There were a range of policies and procedures available that were concerned with infection control these included: • Clinical waste • Spillage of bodily fluids • Laundry health and safety There were sluice disinfectors located on both floors of the home. The home’s laundry facilities were appropriately sited and equipped. The housekeeper said that an external contractor laundered all the home’s sheets and towels and the home only laundered service users personal clothing. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staff working in the home were well trained and supported. There was a good skill mix and they were deployed effectively to meet the needs of service users. Staff recruitment procedures were not sufficiently robust to protect service users. EVIDENCE: Service users and visitors said that staff were able to provide the help and care that they or their relatives needed and they felt staff had the knowledge and skills to provide the appropriate assistance. They also said that there were enough staff on duty in the home at all times and that the nurse call system was responded to quickly. • “I need help for everything and these young nurses know what they are doing” • “I get all the help that I need” • “I have to walk with a frame and when I do there is always someone with me” • “When he needs some help it requires 3 or 4 staff and sometimes at night it means they have to go and find someone but they always do” (visitor). Staff were able to describe the contents of care plans that set out the action staff needed to take to provide the help and support that service users needed. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 19 The home’s staffing complied with the staffing notice issued by the old Southampton and South West Hampshire Health Authority, the body with responsibility for regulating the establishment until April 2002. The minimum nurse/care staffing levels maintained in the home at the time of the inspection was based on the number of service users accommodated and their assessed needs and was as follows: 08:00 to 14:00 2 (2) 3 (4) 5 (6) 14:00 to 20:00 1 (1) 3 (4) 4 (5) 20:00 to 08:00 1 2 3 Registered nurses Care assistants Total N.B. The numbers in brackets and in bold were the numbers deployed when the home accommodated its maximum of 30 service users. At the time of the inspection 25 service users were being accommodated. The registered manager was part of the minimum rota for some of her working week but was supernumerary for 12 to 16 hours a week. Other staff employed in the home included cooks and kitchen assistants, cleaners and a housekeeper and a maintenance/handy person 3 times a week. There was evidence that the home was committed to staff training and development but at the time of the inspection was still working towards achieving the expectation in the National Standards for Care Homes for Older People that 50 of care staff be qualified to National Vocational Qualification (NVQ) level 2. The home employed 13 care staff, 4 of were qualified to at least NVQ level 2 and 7 were pursuing the award. The record of a member of staff that had been employed to work in the home since the last inspection on 2nd December 2004 was examined. It indicated that the person concerned had started work and subsequently information from statutorily required checks was received. In addition the individual had subsequently changed her role and as such the Criminal Records Bureau (CRB) check that had been undertaken may have been at the wrong level. The operations director for Sentinel Healthcare Ltd was asked to verify the situation with the company’s human resources department and if necessary ensure the situation was remedied. At the last inspection of the home, as on this occasion, it was found that a member of staff had started working in the home before a Protection of Vulnerable Adults (POVA) clearance had been obtained from the Criminal Records Bureau. Records examined and discussion with staff indicated that all staff completed a comprehensive induction-training programme and the home regarded training as a priority. Registered nurses and care assistants said that they had attended training courses to ensure that they updated and enhanced their knowledge and skills. All training was appropriate/relevant for the care and Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 20 support provided by the home e.g. catheter care, core values, and abuse, moving and handling, and health and safety, fire safety and infection control. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, and 36 The home’s management approach and systems were good, ensuring the promotion of an inclusive, relaxed and responsive, living and working environment. EVIDENCE: Service users, staff and visitors said many positive things about relationships within the home. Service users confirmed that regular meetings were held in the home at which they could raise concerns and discuss matters that influenced daily life in the home. Minutes of the last meeting were observed in a folder in the home’s entrance hall. Staff also said that they had regular meetings with the homes management and minutes from those meetings were seen. Staff were observed engaging in humorous banter with service users and also service users were observed socialising, conversing and mixing with each Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 22 other. Comments from service users, staff and visitors about relationships in the home and the atmosphere that was generated included: • “I enjoy it, I like the work it’s very rewarding. It’s a good team here and the manager is very helpful, there is always an open door” (staff member) • “The manager seems to have control and she is not remote” (visitor) • “The staff are very willing, very polite and helpful … I get on well with the matron” (service user) • “Its wonderful, its because of the people I work with. The management are good, if I need help they help me and the way the home is run is good” (staff member) • “I don’t hear any grumbles, or moans, it’s not strict, and visitors, friends and relatives are all welcome … we have meetings with matron about food and activities and she comes round and asks us if everything is alright ” (service user) The staff team comprised a gender mix and included individuals from ethic minorities. There was a system in place for monitoring quality. There was documentary evidence that aspects of the home’s service were audited throughout the year (e.g. Care Plans; medication administration charts). Service users confirmed in discussion that they were consulted both informally about the care they received and related matters (see above). One visitor at the last inspection of the home on 2nd December 2004 said that she had been sent a questionnaire by the organisation seeking her views about the quality of the service her relative received. Sentinel Health Care Ltd had employed external consultants to conduct a staff satisfaction survey and had published the results. Representatives from the company undertook statutory monthly visits to the home and assessed aspects of the service and subsequently produced reports of the visits for the home’s manager and copies for the Commission for Social care Inspection. There was a comprehensive range of policies and procedures that informed care and working practices in the home and there was also evidence that they were reviewed updated and developed as legislation and practice determined. Care staff said that they received regular supervision and this was confirmed by a sample of staff and related records that were examined. Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION x 3 x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x 3 x x Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 29 Regulation 19 Requirement The registered persons must not allow new staff to work in the home until all the information and documentaion required in accordance with Regulation 19 (1) and Paragraphs 1 to 9 of Schedule 2 to the Care Homes Regulations 2001(as amended). are in place. (Previous immediate timescale in the report of 2nd December 2004 not met). Timescale for action 16/05/05 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 Good Practice Recommendations Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 Page 25 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cedar Lawn H54 S11416 Cedar Lawn V227408 160505.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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