Inspection on 26/03/08 for Cedar Lodge

This inspection was carried out on 26th March 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cedar Lodge 24/11/06

Cedar Lodge 06/10/05

Cedar Lodge 12/05/05

Cedar Lodge 20/09/04

Cedar Lodge 26/07/04

Cedar Lodge 05/01/04

Similar services:

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Insight - Eastchurch

Southfields

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Cedar Lodge Cedar Lodge Chapel Road Charlwood Surrey RH6 0DA Lead Inspector Lisa Johnson Unannounced Inspection 26 March 2008 12:30 th Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 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 Cedar Lodge DS0000013586.V359208.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 Adults 18-65. 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 Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedar Lodge Address Cedar Lodge Chapel Road Charlwood Surrey RH6 0DA 01293 862050 N/A N/A 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) Ashcroft Care Services Ltd Mr Godfrey Tinashe Mushandu Care Home 6 Category(ies) of Learning disability (0) registration, with number of places Cedar Lodge DS0000013586.V359208.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 - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD) The maximum number of service users to be accommodated is 6. Date of last inspection 24th November 2006 Brief Description of the Service: Cedar Lodge is a large detached home that is situated in a residential area in the village of Charlwood. Surrey. It is close to all local facilities and main services, with local shops within walking distance. The home offers accommodation on two floors for up to six people with learning disabilities. There are six large single rooms, dining room, kitchen, sensory room, two toilets and two bathrooms. There is ample parking and the home has its own transport. Ashcroft Care Services owns and manages the home together with a number of other homes in the area. Cost per: £ 1,626 to £2,048 Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over six and half-hours commencing at 12.30 pm and finishing at 6.55 p.m. Mrs. L Johnson Regulation Inspector carried out this visit. Mr. G. Mushandu Registered Manager represented the home. During this visit we were accompanied by an “ expert by experience”. An expert by experience is a person who because of their shared experiences of using services and/or ways of communicating helped us to get a picture of what it is like to live in the home and their observations are included in this report. During this visit the expert by experience from “My Life My Choice” looked at how people are supported to make choices, control, quality of life and communication. People living in the home have very high communication needs. Two people could communicate using Makaton sign language where staff assisted us to communicate to some of the people who could not use words. However the expert by experience was able to speak to two people without any staff being present to gain their views about the home. Information was sent to us by the service prior to this visit in the Annual Quality Assurance Assessment. (AQAA) This is a self-assessment that focuses on how well outcomes are being met for people using the service. Reference is made to this assessment throughout this report. A full tour of the premises took place. Care plans, risk assessments, medication administration records staff personnel files, training records and policies and procedures were seen during this visit. During this visit we were able to speak to two members of staff. The inspector would like to thank the staff and people living in the service for their time, assistance and hospitality during this inspection. The quality rating for this service is 3 star. This means that people who use this service experience excellent quality outcomes. What the service does well: The home has developed detailed and comprehensive care plans, which are being developed using a person centred approach Each person has a daily file, which shows the persons likes and dislikes so that staff can understand and respond to their needs. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 6 People living in the home have complex communication needs and all the staff have received training in Makaton sign language. During this visit the Expert by Experience saw a member of staff interacting with people using sign language in a way that showed respect, acceptance and understanding of their needs. Two people spoken with who live in the home said that they were happy and said, “nice home”. People living in the service attend a range of activities and during this visit one person was preparing to leave the home to go to line dancing. Another person showed the expert by experience using Makaton about her love of going shopping to buy hats, clothes and hair bands. This person also indicated that that they enjoy going to the disco. Staff receive a wide range of training ensuring that they are able to support the needs of people living in 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. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 People using the service experience excellent outcomes in this area This judgement has been made using available evidence including a visit to this service. Prospective people moving into the home are provided with information they need to consider the suitability of the home as a place to live and their needs are assessed prior to admission to the home. EVIDENCE: The home has a statement of purpose and service user guide in place, which has been reviewed and updated. The guide has been formulated in pictures and symbols. Since our previous visit there have been two new admissions in the home. One person had transferred from another home within the organisation. Records were sampled for these two people. Pre- admission assessments were conducted including any identified risks. Reports had been obtained from the local authority care manager, health care specialist reports such behavioural assessments and speech therapy and previous placement. Visits had been conducted prior to admission and the manager is supported by the organisations central clinical team about the suitability of the placement. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience excellent outcomes in this area This judgement has been made using available evidence including a visit to this service. People are provided with a care plan, which records their individual needs and goals and they are supported to make decisions about their lives. People living in the service are supported to take risks as part of an independent lifestyle. EVIDENCE: Three care plans were sampled. Profiles were completed and histories were available. Care plans were detailed and comprehensive and were based on full needs assessment using a range of tools including health, personal, emotional and social needs. Care plans had been reviewed annually, six monthly and monthly with detailed reports maintained. Clear objectives and goals were recorded. Staff are completing training in person centred planning and one plan was available for viewing which was accessible with pictures. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 10 The expert by experience spoke with the deputy manager who said, “We have started the process of putting together the person centred plan using easy words and pictures”. People are consulted about their care plan and they also consult with families, care managers and other health care professionals to support decision-making People living in the service have complex communication needs and the staff provide assistance and communication support to help people make decisions about their lives. Staff have received training in makaton sign language which was observed during this visit and they have implemented communication passports which assists staff to know and support people likes and dislikes and preferred routines. The expert by experience spoke with a member of staff who said that one person dislikes noise and prefers time on her own. This was demonstrated when the expert by experience observed a senior member of staff interacting with people using sign language in a way that showed respect, acceptance and understanding of their needs. The member of staff explained that one person, although they are unable to use words has speech difficulties when they are worried, so the staff provide him with pen and paper to communicate with them. Another member of staff was also seen using gesture and signs to communicate. Decision and choice making and any decisions made by others were recorded in peoples care plans. This was demonstrated where one person was unable to use a key. The manager had attended training in the Mental Health Capacity Act and has identified further changes. A range of risk assessments were in place, which was regularly reviewed and included, detailed guidelines. Plans sampled included community access; travelling, self help skills, personal hygiene and behaviour support. The company has a clinical behaviour team in place that assists with the implementation of the plans. The manager said that all risk plans are also agreed with care managers. Risk assessments are bought to the attention of staff with a read and sign system in place. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People using the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are provided with a range of appropriate activities and engage in a range of leisure pursuits. People are supported to take part in the local community and their rights and responsibilities are respected. The home is able to demonstrate that people are provided with a well-balanced and nutritious diet. EVIDENCE: People living in the home are supported to access a range of activities such as trampolining, swimming, horse riding, eating out at restaurants, arts and crafts, bowling, going to the disco and shopping. People using the service are also supported to visit the hairdresser; personal shopping and they are supported to participate in household activities. The home has built-up relationships with the local shops and restaurants where they visit who know people by name. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 12 One person using Makaton supported by a senior member of staff told the expert by experience about her love of going out shopping to buy hats, clothes and hair- bands. This person also indicated that she enjoys going out to disco. The senior member staff on duty said: “two of the people regularly go to horse-riding sessions and two other people have regular one-to-one music sessions with a music teacher. During this visit another person was preparing to go out to line dancing which he enjoys. Staff take people to various activities using the homes two vehicles that are large enough to carry wheelchairs. We saw the two large vehicles parked in front of the home. People are supported to maintain links with their family and friends. Some people visit their relatives and they are also provided with the opportunity to visit their family in private in the care home. Relatives are invited to attend reviews and contact is made by telephone. Another person maintains contacts with some old friends. Positive relationships were observed between people living in the home and staff who were interacting and they were all observed to eating their evening meal together. One person was observed signing to a member of staff that she wished to talk to her about something, which this member of staff immediately responded to. The expert by experience spoke with the deputy manager who said that people get up in the morning when they are ready and people get involved with food preparation. One person likes to make their own sandwiches, tea and sets the table for meals. The expert by experience also observed a member of staff knocking on a person’s door seeking permission before entering thus showing respect for their privacy. Another persons care plan identified that they like to eat their meal, alone which was respected during the evening meal. The menu was seen on display in the dining room, which was varied and well balanced. We were informed that meals are prepared freshly which was demonstrated during the evening meal, which was well presented. Information was seen in some people’s files where consultation has taken place with a dietician. Menus are based on people’s likes, dislikes and preferences. The mealtime was unhurried and relaxed and everybody was observed to be enjoying their meal. Some people were provided specialised utensils and plates to assist them to maintain their independence with eating. It was recommended that the menu would benefit from being more accessible such as formatting this in large print and providing pictures to assist people living in the service. The manager had recognised this as an area for improvement in the Annual Quality Assurance Assessment. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 19 & 20 People using the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people living in the service receive personal support in the way they prefer. People’s physical and health needs are met and they are protected by robust medication administration procedures. EVIDENCE: Peoples care plans identify their likes and dislikes and their preferred routines. One persons care plan identified that they dislike noise. One person was observed to have an early bath before their supper where she uses the Jacuzzi. We were informed that this is this person’s preference, as they like to go to bed early. The health care needs of people were documented including primary health checklists. Information recorded demonstrated that people are supported to access a range of health care professionals including a local general practitioner, dentist, chiropody and dietetic input. Detailed records were Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 14 maintained of all consultations. Weight charts were maintained and one person who has epilepsy had monitoring records in place. The home was also able to demonstrate that a health care specialist has visited the home to conduct training with staff to meet the needs of one person who requires support with a medical appliance. This person had recently been discharged from hospital. Since the previous visit the organisations medication policies and procedures have been reviewed. Medication was stored appropriately and records were maintained of all medication received and disposed of. A list was maintained of all staff that are trained and authorized to administer medication. All medication administered had been signed for and a photograph of each person was maintained with their medication administration record Medication is dispensed using the Monitored Dose system (MDs system). Protocols were in place for the administration of as required medication. Staff receive medication training and work through a package with the manager, which consist of three units. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 33 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of people are listened to and acted upon and they are protected from abuse. EVIDENCE: The home has a complaints procedure in place, which is also accessible in symbol format. The Organisation is currently in the process of updating their procedure, which should be available shortly. Since the previous visit one complaint has been received by the home, which was dealt with promptly by the organisation. The Commission has received no complaints. Although it is recommended that the home maintain a written record of any complaints received with the outcome made available for inspection. The expert by experience was able to two talk to two people without the presence of staff who indicated that they were happy and said “nice home” Since the previous visit the organisation has implemented new safeguarding adults from abuse procedures, which were detailed and comprehensive. The local authority safeguarding vulnerable adults procedure was also available. Staff training records were sampled for three members of staff, which confirmed that they had attended up to date training in this area. The manager has also attended training conducted by the local authority. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 16 Since the previous visit there have been no matters referred following the local authority safeguarding vulnerable adults from abuse procedures. A member of staff spoken with was clear about the procedures and had awareness of the action they should take if they witness or are made aware of any incident where the safety or protection of a vulnerable person is compromised. Staff also attend training in Non Violent Crisis Intervention training and challenging behaviour training ensuring their understanding. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a well-maintained, comfortable, homely and safe environment. EVIDENCE: The home is situated in a rural village close to local shops and is nearby to Horley and Crawley town centre. Since the previous visit, major work has commenced to improve the environment, which was still ongoing during this visit, which needs to be completed. The kitchen has been relocated to the front of the house, which now provides a spacious open plan dining area. Two people’s bedrooms have been decorated and a bathroom floor has been upgraded. Furniture provided in the home was modern and domestic in style and people also benefit from having a Jacuzzi available in one bathroom. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 18 There is a large, accessible and well-maintained garden to the rear of the house, which has been re-landscaped. During a tour of the home one health and safety matter was identified that must be attended to (See also standard 42). Each person has their own bedroom, which were viewed by the expert by experience who said, “Each person had their own DVD, music centres and photographs of their family and they were clean and tidy”. It was observed that the home was clean and hygienic throughout. Infection control procedures were in place and staff receive instruction as part of their health and safety training. Information supplied in the Annual Quality Assurance assessment states that cleaning schedules are in place. Laundry facilities are also located away from the kitchen. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The current staffing arrangements in the home meet the needs of people living in the service. People are supported by staff that have the appropriate qualifications and skills and they are protected by robust recruitment procedures. People using the service benefit from staff that are supported and supervised. EVIDENCE: There are currently four people living in the home who were supported by four members of staff, which included the registered manager. At night time there is a waking and sleep-in member of staff provided. There are ten permanent members of staff employed by the home that are of mixed ethnicity and the manager ensures that the duty rota ensures that there is a mix of staff which reflects gender, experience, skills and responsibilities. Staff are also provided with job descriptions and the General Social Care Code Conduct. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 20 Staff are supported to attend training and development, which was demonstrated by training records and certificates sampled for three members of staff. It was clear that staff had attended up to date statutory training which is required including safeguarding adults from abuse, health and safety, fire awareness, food hygiene and hygiene. Information supplied in the Annual Quality Assurance Assessment state that all shift leaders are trained first aiders. The organisation has a training manager in post and the manager has implemented individual training development plans. It was observed that staff receive a range of training that supports the needs of people currently using the service including epilepsy, makaton sign language, autism, Non Crisis Intervention, challenging behaviour, risk assessment and a health care professional has also visited the home recently to carry out training with staff to support one person who has acquired some physical needs. Staff have also been receiving training in equality and diversity and person centred planning Information supplied with the Annual Quality Assurance Assessment states that three members of staff hold National Vocational Qualifications (Level 2) or above and three members of staff are working towards completing the programme. New staff receive induction based on good practice and a probationary period follows which is reviewed monthly Recruitment is based on an equal opportunities policy. Prospective employees visit the home and have the opportunity to meet and interact with people living in the home who are involved in the selection process. The personnel files were sampled for three members of staff these were well maintained and contained all of the required information including an application form with full educational and work histories, two written references and enhanced Criminal Record Bureau Checks (CRB). We were informed that nobody commences employment until this information is received. Staff receive regular, formal supervision, which were available for viewing in staff personnel files sampled. Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. An experienced registered manager manages the home, which is run in the best interests of people, and their health and safety is mainly protected. EVIDENCE: The registered manager has experience of working with people with learning disabilities and holds the Registered Managers Award. The manager is completing a degree in social care management and leadership and another degree in business management. The manager is also supported by a deputy manager who is completing a National Vocational Qualification (Level4). The home was observed to be run well and good lines of communication was observed. One member of staff spoken with said that regular team meetings Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 22 are held and that there is good teamwork. The manager demonstrated that he maintains good record keeping which well-organised files observed. The provider conducts monthly quality visits, which were available for viewing, there were reports missing on two occasions, although the organisation has now addressed this matter. Information supplied with the Annual Quality Assurance Assessment stated that annual feedback surveys were provided to relatives in December 2007. A report on the outcome was available for viewing, although it was recommended that the outcomes specific to the home be made available with the service user guide. There are a range policies and procedures in place, which are currently being reviewed by the organisation, as there are a number of them that are out of date and there are plans to introduce a staff handbook. There is a health and safety policy in place. Information supplied in the Annual Quality Assurance Assessment indicates that regular servicing and maintenance of equipment is conducted including portable electrical testing gas appliances .The premises electrical circuits have not been serviced recently therefore the manager was advised to follow up with the health and safety department to seek clarification. There are new fire risk assessments in place for fire safety and records sampled confirmed that regular fire drills and alarm checks are conducted. The home conducts regular checks for water temperatures and written records are maintained. Substances hazardous to health were stored appropriately. During a tour of the premises is was observed that there was a step at the exit of what used to be the old kitchen and another step in one persons bedroom which had no visible advanced warning notice or picture to highlight that this could be a hazard. Therefore it was required that this matter must be attended to and that consultation takes place with the Environmental Health office ensuring the welfare and safety of people living in the home. Cedar Lodge DS0000013586.V359208.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 Adults 18-65 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 4 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 X 3 X X 2 X Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 24 No 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 YA37 Regulation 13(4)(a) (c) Requirement The registered person must place a warning sign identifying that the two steps inside the house are a safety hazard. Timescale for action 26/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA22 YA39 Good Practice Recommendations It is recommended that the registered manager maintains a written record of any complaints received by the home It is recommended that the home maintains a report of the outcomes from feedback surveys for the home Cedar Lodge DS0000013586.V359208.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Cedar Lodge DS0000013586.V359208.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. 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