Inspection on 12/10/06 for Cedarwood Lodge

This inspection was carried out on 12th October 2006.

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

Cedarwood Lodge 19/09/05

Cedarwood Lodge 25/07/05

Cedarwood Lodge 20/09/04

Cedarwood Lodge 20/05/04

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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 Cedarwood Lodge Cedarwood Lodge Chipstead Close Redhill Surrey RH1 6DU Lead Inspector Sandra Holland Unannounced Inspection 12th October 2006 10:30 Cedarwood Lodge DS0000013589.V311545.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 Cedarwood Lodge DS0000013589.V311545.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. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedarwood Lodge Address Cedarwood Lodge Chipstead Close Redhill Surrey RH1 6DU 01737 277726 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) Surrey and Borders Partnership NHS Trust Mrs Julie Anne Parker Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1), Physical disability (5) of places Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 5 persons accommodated may be in the category LD (Adults with learning disabilities) or may be Adults with a learning disability who have an additional physical disability (LD/PD). 19th September 2005 Date of last inspection Brief Description of the Service: Cedarwood Lodge is a purpose built bungalow owned by a private housing association. The home can accommodate up to five severely disabled service users and is situated in a quiet residential area of the town of Redhill, with easy access to the town centre and local amenities. The home provides care and support to four service users who have profound learning and physical disabilities and there is currently one vacant room. Accommodation is in single bedrooms, which are arranged off of a wide, easily accessible corridor. A large, bright and spacious lounge/dining room is available for communal use. There is a good-sized paved garden to the rear of the house, with a number of raised beds and shrubs. The level garden provides an even surface for the service users who are all wheelchair bound and can be accessed from the lounge. Service users are protected from the sun by an electrical retracting awning, installed to the rear of the building. There is limited parking space to the front of the building. The fees at this service range from £1800.00 to £1900.00 per week. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was the first to be carried out in the Commission for Social Care Inspection (CSCI) year, April 2006 to June 2007 and was carried out under the CSCI “Inspecting for Better Lives” programme. Mrs Sandra Holland, Regulation Inspector carried out the inspection over six and a half hours. Mrs Julie Parker, Registered Manager was present representing the service. A full tour of the premises was carried out and a number of records and documents were sampled, including individual plans, staff files, medication administration record (MAR) charts and service user’s monies records. The home was supplied with a pre-inspection questionnaire, which was completed and returned within the requested timescale. Some of the information supplied in the questionnaire will be referred to in the report. A number of CSCI feedback cards were supplied to the home for distribution to all those involved in the support of service users. Two of these have been returned and both made positive responses regarding the support and care provided. The inspector would like to thank the service users and staff for their hospitality, time and assistance. As the inspector was not able to directly communicate with the service users, their responses and reactions were observed, in addition to their facial expressions and body language. What the service does well: The service users receive a high level of individual support to meet their specific and very dependent needs. Most of the staff have worked at the home for a number of years and have developed a very good knowledge and understanding of each service users’ support needs, likes and dislikes. The home is spacious, light and airy and is well equipped to meet the mobility needs of the service users. It is decorated and furnished in a homely style, with a level access to all areas to enable service users to be as independent as possible. Staff provide excellent support to enable service users to take part and enjoy their activities and to be involved members of their community. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Cedarwood Lodge DS0000013589.V311545.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 Cedarwood Lodge DS0000013589.V311545.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of any prospective service user would be fully assessed before they moved into the home. EVIDENCE: The four service users who live at the home have lived there for many years, since the home was opened as a newly built service, having transferred from a large, local hospital which had closed. The manager stated that there has been a vacant room at the home for approximately two years. A number of prospective service users have been referred to the home during this time, but the home has either not been able to meet their needs or the home has not suited the service user, the manager advised. The manager was able to describe the assessment process that would be carried out to ensure that the home could meet the needs of a prospective service user and that any new service user would be compatible with the existing group. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 9 As most prospective service users are funded by a local authority, a full needs assessment would be carried out under the care management process and a copy of the assessment would be obtained. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 10 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive individual plans and assessments of risks are in place to guide staff to the support and care needed by each service user. Due to the needs of the service users, staff or service users’ representatives make most of the decisions required, on behalf of the service users. The decisions that are taken, reflect the known preferences of the service users. EVIDENCE: The individual plans for three service users were seen. These were comprehensive and provide staff with effective guidance as to the support and care needs of each service user. The manager stated that the service user plans are being reviewed and revised, with the aim of incorporating all information into one holistic record, which should be more user-friendly and accessible for staff. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 11 It was pleasing to see that service users’ individual plans recorded their needs and goals and included an action plan as to how these would be met or achieved. Staff advised that the service users are not able to make their own decisions, due to the level of their disabilities. Staff therefore make most decisions for service users, using their well developed knowledge of the service users’ likes dislikes and needs. Although all service users require assistance to eat, it was clear that service users could choose whether to eat or not. At lunchtime one service user did not wish to eat the main course that was offered despite the gentle encouragement of staff. This choice was respected and an alternative, preferred food item was offered. The manager advised of the decision making support provided to a service user who had an operation earlier in the year. As the service user was not able to give his consent to the operation, a multi-disciplinary meeting was held to decide and agree if appropriate, that it was in the best interests of the service user to have the operation. All those involved in the support of the service user were invited to attend and the decision which was made, was then submitted to the service user’s surgeon. The surgeon was responsible for making the ultimate decision about the operation, with the knowledge that all those involved had agreed it was in the service user’s best interest. It was pleasing to hear that the operation had been carried out successfully and a healthcare professional involved has given positive feedback as to the skilled care and support provided by staff when the service user returned home. From the individual plans it was clear that any risks to service users have been assessed, recorded and where possible minimised. A number of risk assessments were seen for each service user and these reflected their needs and differing activities. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 12 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 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are actively supported to take part in a wide range of activities and to be visible and valued members of their local community. Staff enable service users to maintain their family links. Well-balanced meals are provided to meet the needs of the service users. EVIDENCE: Staff advised that they support service users to be active members of their local community and this was seen on the day of inspection. Two service users went out to local shops with two staff, to buy items for the lunch-time meal and their personal choice of confectionery. Two other service users also went out separately, with their “one-to-one” day service support workers. One service user went for a pub lunch a short car ride away, which overlooks a local beauty spot and the other service went out for a “walk” in his wheelchair to a nearby park. The home has a wheelchair Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 13 accessible vehicle to transport service users to activities, outings and appointments and the manager advised that staff are allocated to ensure that at least one driver is available on every shift. It was evident that all four service users have a busy life with a range of occupational and leisure activities to take part in. A chart of everyone’s activities is displayed in the kitchen and details of this are also contained in the service users’ individual plans. The activities listed include a drop-in club, gardening, music, “Us in a Bus” stimulation sessions, aromatherapy, swimming, cooking and ice skating. The home has a large selection of videos and DVD’s to provide entertainment at home. A spacious, level, easily accessible garden is available to service users and it was good to see that tomatoes and beans were being grown, in addition to shrubs and flowers. A large table and chairs in the garden enables service users, staff and visitors to enjoy their meals outside. This was enjoyed on the day of inspection, as it was warm and sunny. Staff advised that all service users have family supporters with varying degrees of contact. One service user is able to go to visit his family occasionally, supported by a one-to-one member of staff. It is difficult for service users to make new friends because of their communication difficulties staff advised. A four week menu plan is displayed in the kitchen and this offered a selection of well-balanced and healthy meals. Staff advised that one service user has a medical restriction on certain aspects of his diet and this was noted alongside the menu plan for ease of reference. Staff stated that wherever possible, the meals for this service user were the same as that for other service users, with amendments made to suit his requirements. Service users and staff were seen to enjoy their lunchtime meal, with each service user being assisted, family style, by a member of staff. The assistance provided was given in a relaxed, patient and sensitive manner and it was noted that for some service users the meal had been prepared in a pureed form, to meet their specific needs. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 14 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): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported in the way they prefer whenever possible and their healthcare needs are very well met. The administration of medication is appropriately managed. EVIDENCE: Staff advised that although the service users have communication difficulties, they were still able to convey a preference for the way that they are supported and by whom. It had been noted that some of the service users are more cooperative with certain members of staff or staff of the opposite sex. Where these preferences are noted, they are recorded to guide staff and are respected whenever possible. Service users’ rooms and the home generally, are well-equipped with specialist equipment such as hoists and easy access baths and showers, to meet the service user’ needs and preferences. The manager stated that specialist support, such as from physiotherapists or speech and language therapists, is sought as soon as required, to meet any changing needs of the service users. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 15 It was clear from speaking to staff and from the records in the individual plans, that service users’ healthcare needs are well met. A number of healthcare professionals are involved in the support of service users, including general practitioners (GP’s), community nurses, chiropodist, dietician and dentist. Staff advised that they have learnt to recognise changes in the service users’ behaviours, which may be an early indication of a change to the service users’ health. It was pleasing to see that very good guidelines have been drawn up to use in assessing a service users health. These would be very useful to new or agency staff, who had not yet developed a detailed knowledge of the service users. The manager stated that very little medication is used at the home, although a number of nutritional supplements are prescribed to service users. Any medication which is required is usually prescribed in a liquid form as this suits the service users better. The medication which is prescribed is stored appropriately in a locked provision and is only administered by staff who have been trained to do so the manager stated. The amount of medication held in the home was checked with the record held and these accurately matched. It was pleasing to note that there were no gaps in the recording of medication administered. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 16 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): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No complaints have been recorded for two years, but staff are alert to any changes in service users’ moods which may indicate unhappiness. Staff are aware of their role in the protection of service users. EVIDENCE: As all of the service users have communication difficulties and cannot make a verbal compliant, they are reliant on staff observing changes in their behaviour, facial expression of body language, to express any unhappiness or discontent. As noted previously, staff stated that they are very aware of any change in a service users’ mood and would quickly look for the cause of this. The home’s complaints procedure was displayed in a written format in the corner of the lounge, just outside the office. Staff advised that the service users would not be able to access the procedure, even if it was made available in alternative ways. The complaints record was seen and no complaints had been recorded for two years. The manager advised that complaints had previously been made by neighbours, but these had been responded to and the relationship with neighbours was now much improved. Staff spoken to stated that they are very aware of the vulnerability of the service users and of their own role in the protection of service users. Staff stated that they would have no hesitation in reporting any concerns about abuse or suspicions of abuse, to the manager or person in charge. Staff were Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 17 also aware that they could report these to the area manager if they felt that appropriate action was not being taken. The manager stated that in the event of any incident of, or allegation of abuse, the home would follow the Surrey Multi-Agency procedure for safeguarding vulnerable adults. A copy of this procedure was available in the home and was the most recent version. The home’s policy regarding abuse links with the Surrey policy and it was pleasing to see a poster on the office door outlining steps for staff to remember about adult protection. A small amount of money is held for safekeeping on behalf of the service users staff advised, to enable them to make purchases and pay for hairdressing and towards outings and holidays. A receipt is obtained for all purchases, is kept to ensure that service users’ monies are appropriately used and this is logged in the record kept for each service user. To safeguard service users and staff, the monies held are checked at each shift handover by the staff going off and the staff coming onto their shift. The record and the monies held were checked and accurately matched. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well suited to the needs of the service users, is decorated and furnished in a homely style and all areas were clean and freshly aired. EVIDENCE: The home, a purpose built bungalow, is situated in a small residential close and is surrounded by similar properties. It is well suited to the needs of service users, with all rooms opening from a wide, bright corridor which is lit by a skylight. All areas are completely level, ensuring a smooth ride for service users, three of whom use wheelchairs at all times. Doorways, bathroom, shower and toilet facilities are all wheelchair accessible. Up to five service users can be accommodated at the home, but one room has been vacant for approximately two years the manager advised. Each service user has a single bedroom, furnished and equipped to meet their individual needs and tastes. The communal areas are spacious, with furniture arranged to enable wheelchair users to have easy access. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 19 It is commendable that the home was freshly aired, attractively decorated and furnished in a comfortable and homely style given the very highly dependent needs of the service users. Only one shortfall was noted, in that the carpets in some areas of the home, particularly one service user’s bedroom were marked or stained. It is recommended that these should be cleaned or replaced. All areas of the home were clean and appeared hygienic, with hand-washing facilities, liquid soap and paper towels provided in all appropriate places. Staff were observed to use personal protective equipment including gloves and aprons, to prevent the spread of infection. The manager advised that the home has a contracted collection of its clinical waste and an appropriate bin is stored outside in an enclosed area. A laundry room is situated very practically near the service users’ bedrooms and bathrooms, which prevents laundry having to be carried through the home. The room is well equipped, the washing machine has appropriate settings and there is a locked storage facility for products which are hazardous to health. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 20 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): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are effectively supported by a stable, experienced and trained staff team. Recruitment of staff is appropriately managed. EVIDENCE: From the information provided in the pre-inspection questionnaire, it is clear that the service users are supported by a small, stable team of staff, most of whom have worked at the home for many years. Staff advised that they take part in all roles within the household, including personal support, shopping, cooking, domestic and laundry tasks and activities. Staff were observed to interact with service users in an informal and relaxed, but appropriate manner. Staff were sensitive to service users’ needs and offered personal support in a discreet way, promoting privacy and dignity. The manager stated that a number of staff have achieved or are undertaking a National Vocational Qualification (NVQ) to level 2 or 3 in care. Two members of staff have achieved NVQ level 2, one is undertaking it and two others have Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 21 been registered to start. One member of staff has achieved NVQ level 3 and two others are undertaking it. Only two members of staff have been employed within the last two years, as all other staff have worked at the home for at least five years, providing continuity and consistency of support for service users. The files of the most recently recruited staff were seen and as all required records and documents were present, recruitment is clearly well managed. Staff advised that their training needs are discussed within their supervision and appraisal meetings with the manager, but requests can be made at any time. They advised that the manager is supportive to any requests for staff training that will benefit service users. Staff training records were seen and these indicated that staff receive training required by law, such as fire safety and food hygiene, as well as training to develop their knowledge and skills such as health and safety, NVQ’s and intensive interaction. It was noted that the service user group is all male whilst the staff team was of mixed gender and there is cultural and racial diversity amongst the staff team which is not reflected in the service user group. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 22 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced and well qualified person and the health and welfare of service users is promoted. A quality assurance system is being developed and should be supplied to all those involved in the support of service users. EVIDENCE: The manager stated that she is a qualified nurse, has achieved an NVQ in Management Studies, a Certificate in Management Studies (CMS) and has undertaken the NVQ Registered Manager’s Award (RMA). The manager advised that she has worked at the home since it was opened and prior to that was employed at the hospital where the service users were previously living. The manager is very experienced in the support and care of service users with complex learning disabilities and is well qualified for her role. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 23 Due to the level of their disabilities, the service users are not able to convey their views of the quality of the service provided, but a survey of relatives views was carried out in April 2005 the manager advised. Two of the four surveys were returned and gave positive feedback the manager stated. The manager advised that the managing organisation for the home, the Surrey and Borders NHS Trust is developing a corporate quality assurance system, as there is currently no effective quality assurance system being carried out at homes within the group. It is recommended that when the quality assurance system is established, it is supplied as soon as possible, to all those involved in the support of service users, to obtain an independent view as to how he home is meeting the needs of the service users. This is particularly important, given that service users are not able to give their views in any way and because no survey has been carried out for over a year. The health, safety and welfare of service users is promoted and protected. Information supplied with the pre-inspection questionnaire confirmed that maintenance checks and servicing of equipment is carried out regularly and to the required frequencies. This included testing and checking of fire safety equipment, fire drills and alarm testing, checking of the gas and electrical supplies and specialist maintenance checks on the hoists and specialist baths in the home. The manager stated that cleaning and other similar products are obtained from high street suppliers and that safety information relating to the use of these products is obtained. It was pleasing to see that a new product which had been purchased, was marked as not to be used, until the Control Of Substances Hazardous to Health (COSHH) information had been obtained, to safeguard service users and staff. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 24 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 x 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 x Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 YA24 YA39 Good Practice Recommendations It is recommended that the carpets in some areas of the home, including one service user’s bedroom, are cleaned or replaced. It is recommended that the quality assurance system to be established, should be supplied to all those involved in the support of service users. Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Cedarwood Lodge DS0000013589.V311545.R01.S.doc Version 5.2 Page 27 - 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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