Inspection on 23/10/07 for Conifer Lodge

This inspection was carried out on 23rd October 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conifer Lodge 22/09/08

Conifer Lodge 06/06/06

Conifer Lodge 08/11/05

Conifer Lodge 12/07/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Conifer Lodge 134 North Brink Wisbech Cambridgeshire PE13 1LL Lead Inspector Elaine Boismier Unannounced Inspection 23rd October 2007 9:30 Conifer Lodge DS0000062547.V353502.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 Conifer Lodge DS0000062547.V353502.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. Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conifer Lodge Address 134 North Brink Wisbech Cambridgeshire PE13 1LL 01945 474912 01945 583951 john.baker@erminecare.com 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) Ermine Care Ltd Ms Dianne Pauline Eaton Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: Conifer Lodge is an adapted two-storey domestic dwelling situated on the outskirts of the Cambridgeshire market town of Wisbech and is in walking distance from the town centre. Local amenities include shops, pubs and leisure facilities. The home provides accommodation care and support for a maximum number of 15 people, between 18 and 65 years of age, with a learning disability. All bedrooms have ensuite facilities and are for single occupancy. In addition to the ensuite facilities the home provides 3 toilets and has two bathrooms. There are two communal rooms and a large garden that provides space for games and gardening activities. Care Principles Ltd became the new owner of Ermine Care Ltd, the registered provider of Conifer Lodge, on 1st April 2005. Current fees range from approximately £1800 to £2200. Further information about the fees can be obtained from the home. Additional costs include those for toiletries, cigarettes and contributions to holidays. A copy of the inspection report is available at the home or via the CSCI website. Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We, the Commission for Social Care Inspection, carried out this key unannounced inspection of Conifer Lodge between 9:30 and 14:20, taking almost 5 hours to complete. Before the inspection we received information about the home from surveys that we had sent out to residents and their relatives. We received also information in the annual quality assurance assessment (AQAA) that the Manager had completed and information provided to us from both the home and the registered owners since the last inspection in June 2006. At the time of this inspection, of 23rd October 2007, there were 15 people living at Conifer Lodge and some of these people we spoke with. We spoke also to visitors, staff, including the Registered Manager, examined documentation and looked around the premises. Conifer Lodge continues to provide a good quality service. For the purpose of this report the people that live at Conifer Lodge are referred to as “resident”,” people” and “service users”. What the service does well: What has improved since the last inspection? Since the last inspection the home has met the following requirements. Two requirements were made regarding the Statement of Purpose and Service User’s Guide. Both Statement of Purpose and Service User’s Guide have been updated and copies of these were given to us at the time of the inspection. These two requirements have therefore been met. Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 6 Two requirements were made with regards to medication. The medication records were accurate and all labels on medication containers were intact. As a result of these findings both of these requirements have been met. A requirement was made, and had been carried forward, with regards to information about staff. All the required information had been obtained about staff and as a result of this evidence, this requirement has been met. 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. Conifer Lodge DS0000062547.V353502.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 Conifer Lodge DS0000062547.V353502.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 & 4 Quality in this outcome area is good. Prospective residents have a good standard of information about the home to help them in their decision where to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two requirements were made regarding the Statement of Purpose and Service User’s Guide. Both of these documents were updated in August 2006 and copies of these were obtained at the time of this inspection. Both of them were satisfactory and, as a result, both of these requirements have been met. A recommendation was made that the Service User’s Guide to be made available in a format that every person could understand. According to the Manager this is not yet available. The Manager reported that this is being considered at a higher administrative level of the company and organisation. This recommendation remains although will not appear in the recommendation table of this inspection report. Of the 13 residents’ surveys 10 of these said that the person had received enough information about the home before moving in; two of the 13 surveys stated that the person had received no such information. The remaining survey said that the person was unable to remember if they had received this information. Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 9 Two newly admitted residents’ files were examined. Both people had transferred from services owned by the registered owner, had visited the home before living there and had been subject to ongoing reviews and care planning, prior to moving in to Conifer Lodge. Reviews had been carried out, following the person’s admission to the home, by a number of people including a consultant psychiatrist and people working at the home. These reviews were to ensure that the home was able to meet the needs of the people. Staff and the Manager informed us that there has been some change in the admission criteria of the home. Conifer Lodge, when first registered by us, was intended for the rehabilitation of younger people to learn independent living skills with the potential of moving to a place where the person required less support. We spoke to staff and a visiting social worker and evidence suggest that some people are progressing to a level where they could live in a more independent supported living environment. Staff expressed some concern that due to a change of the admission criteria of people that some people do not have the potential to gain benefits from rehabilitation programmes. Staff and the Manager considered that this might be due to the older age of some of these people. We consider that should there be a change in the admission criteria of the home, and a change in provision of the service, then the Statement of Purpose must be amended to reflect this change. Conifer Lodge DS0000062547.V353502.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 & 9 Quality in this outcome area is excellent. People are provided with excellent opportunities to live a life as independently as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two care plans that were examined provided excellent detail of how the person should receive care and support and that these care plans were based on risk assessments. People that we spoke to knew what they wanted to do and what they were going to do and we observed staff were supporting residents in their choices such as washing up, shopping, managing personal allowances and recycling waste such as aluminium cans. Three of the 13 residents’ surveys said that the home always allowed the person to make decisions about what they could do each day; 6 of these surveys said that the home usually allows the person to make decisionabout what they could do each day; 4 of these surveys said that sometimes the person was allowed to make decisions about what the person could do each Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 11 day. The remaining survey was not completed in this area. Information provided also from these surveys indicated that on the whole people are allowed to do what they wanted to do during the day time and and during the evening. This also included at weekends. Conifer Lodge DS0000062547.V353502.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): 12,13,14, 15, 16 &17 Quality in this outcome area is excellent People are offered an excellent range of opportunities to live a good quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the Manager eleven of the 15 current residents attend college. This information was noted also on the activities board located in one of the administration offices. A person that we spoke to said that they enjoyed going to college and was learning computer and cooking skills. On the day of the inspection people told us that they were supported by staff to go into the local town and these visits were recorded in the person’s care records. Such visits included going to the local cafes and library. At the time of the inspection we noted that people were getting ready to go into the local town to shop with the support of staff. Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 13 The AQAA told us, “Holidays are taken on an individual basis or in small groups, depending on the service users wishes and the assessed risks. The locations have been diverse, from camping in Great Yarmouth to going abroad to Turkey, again taking choice and risks into account.” Staff confirmed that people have been away on holiday with support from staff, including a holiday in Turkey. There are a range of leisure pursuits avalaible for people including Sunday markets, bowling , playing snooker , go-karting and walking. Photographs on a notice board showed people visiting Manchester United Football Club and celebrating a resident’s birthday in the way that the person had chosen (custard pie throwing). On the day of the inspection some people were going to a go-karting circuit. The AQAA told us that “Contact and involvement with family and friends is encouraged and supported. This includes transporting service users to the family/friends home for visits, supporting them to write letters, welcoming visitors and supporting service users with personal relationships.” People we spoke with said that they visited their family homes and at the time of the inspection a person was returning, with their relative, having spent a weekend away fom the care home. People that we spoke with said that they had keys to their own rooms and they showed us these keys. Staff asked people’s permssion before going into their bedrooms. Examination of the menus indicated that people have a range of food from risotto and tagliattelle to the “traditional” English food. The regulation 26 report for May 2007 informed us that, “The residents seen on this visit were more than happy with the quality and range of meals that they receive. Opportunities to prepare their own meals was (sic) discussed. Much better now that the ‘kitchenette’ is being used regularly.” The AQAA told us “Service users have their own kitchenette and following risk assessment, have access to make drinks and snacks. Many service users plan,shop for and prepare their own meals.” We noted that people were able to go in and out of the kitchenette area and help with washing up and make a drink. Care records, for one of the people living at the home, showed that the person had been supported to shop for food and that the person cooked this after the shopping trip. Minutes of the last two residents’ meetings showwed that food was discussed, by residents, and what they liked and disliked. Conifer Lodge DS0000062547.V353502.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 & 20 Quality in this outcome area is good. People benefit from a good standard of health and person care that has some areas that could be improved upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care records of two people were examined and these provided clear details of how the person was supported in their personal care. Minutes of a residents’ meeting recorded that residents were reminded of their own responsibility of maintaining their own personal care. A visitor to the home reported that their relative had improved since living at Conifer Lodge, and this improvement was shown by the person being calmer than before. People that we spoke with, and observed, seemed generally happy and there was a lively atmosphere to the home. Staff and a visitor reported that a small number of residents, who have benefited from the care and therapy received whilst living at Conifer Lodge, are leaving to live in a more independent care setting. Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 15 Care records and financial records indicated that people receive chiropody services and psychiatric services. Medication records indicated that residents have access to GPs. Two requirements have been met with regards to medication. These were related to medication records and the labels (that had the prescriber’s instructions on) on medication containers. Medication records were satisfactory and all of the medication containers that were seen had labels on. Stock levels were satisfactory and the storage of medication was good. Temperatures of the drug fridge were recorded daily and these were satisfactory. The medication room temperatures were recorded also daily. It was noted that on the odd occasion the temperatures of this room exceeded 25 degrees centigrade. Staff reported that the window of the room is opened to ensure that medication is stored at appropriate temperatures. Discussion with staff, including the Manager, indicated that a requirement, made following the inspection of June 2006, has not been met. This requirement was regarding medication for people going out of the home on leave and secondary assemblage of medication was being carried out by staff for these people to take with them. Such practice is not safe and is not within the Nursing and Midwifery Council guidance. However the Manager stated that she had taken action, in response to the requirement made, although was informed by the local pharmacy that they would be unable to provide such a service (to dispense medication specific for people going on leave). We have offered advice to the home what action could be taken to meet this requirement. Whilst acknowledging that there have been difficulties encountered, in meeting this requirement, this requirement remains and has been carried forward with a new timescale for action. A recommendation was made for the home to consider ways if any person could self-medicate. This recommendation has been considered as during the inspection we were informed that some residents have been assessed to be able to give their own medication. No formal assessment, including risk assessments, however, has been carried out. We expect the home to manage this, rather than we make a requirement on this occasion. Conifer Lodge DS0000062547.V353502.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 & 23 Quality in this outcome area is good. People are listened to and are safe from the risk of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the surveys from residents said that the person knew who to speak to if they were unhappy and 10 of these 13 surveys said that the person knew how to make a complaint. We expect the home ensures that every person is provided with information about how they can make a complaint, if they want to do so. The residents’ surveys told us that generally people felt that staff listened to them although three of these 13 surveys informed us that it was only “sometimes” the person felt that staff listened to the person. According to the AQAA the home has responded to 66 of the 3 complaints that have been received within the last 12 months. Of those complaints that have been investigated the AQAA told us that none of these complaints had been proven. We have received no complaints about the Conifer Lodge. The Manager said that since she has attended a course on how to deal with complaints she has an increased awareness of recording concerns as well as complaints as part of a quality assurance system. Since the last inspection we have received information about allegations of abuse and we are satisfied that the home has taken appropriate action in responding to these allegations. Records for staff attending training, in Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 17 safeguarding vulnerable adults against abuse, were not available for inspection although staff that we spoke with said that they had attended such training. We saw evidence to suggest that arrangements are in place for staff to attend such safeguarding training in December 2007. A recommendation was made for records of people’s personal monies, and the amounts, to be accurate. Two people’s personal monies were counted and these reconciled with the record of balances. This recommendation has been considered. The record of restraints was examined and these records indicated that restraint was warranted when people’s physical safety was at risk. Conifer Lodge DS0000062547.V353502.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 &30 Quality in this outcome area is adequate. People live in a home that is generally well-maintained but could be improved upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We received reports for May and June 2007 of visits by a manager of the registered owner. These reports noted that carpets needed some cleaning; that the home was kept in a good state of repair and replacement furniture in bedrooms was planned on a staggered basis. At the time of our inspection the indoor areas were well decorated. The AQAA informed us that, “Three service users have had their rooms redecorated in colours of their choice. New bedroom furniture has been purchased for three rooms.” Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 19 We noted that two floors, one in the conservatory area and one in the lounge area, had holes in the floor covering. The Manager explained that this was due to furniture damaging the floor covering. It was reported to us, however, that action has been taken, to improve the floor covering. Minutes of a residents’ meeting record people’s views about the sofas and these views were that the sofas were uncomfortable to sit on. Staff, including the Manager, confirmed that money has been released for the furniture to be replaced. Garden areas were fairly well kept although some lawn areas were in need of mowing. The Manager informed us that there is a limited budget for garden maintenance. The vegetable patch was in a state of neglect and was currently used for garden refuse. The Manager reported that this area has been neglected as the home is waiting for the installation of the drainage system. The waste drainage system of the home is under review. A gulley, close to the conservatory area, had rainwater in it. According to staff, this is emptied 6 times a week (to reduce the risk of air borne disease from stagnant water). The majority of residents’ surveys said that the home was always clean and fresh although two of these surveys said that the home was never clean and fresh. On the day of the inspection the home was clean and there were no offensive smells. Conifer Lodge DS0000062547.V353502.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 & 35 Quality in this outcome area is good. People receive safe and appropriate care from staff who are wellrecruited and generally well-trained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA told us that a majority of care staff have NVQ level 2 in care. This is currently 62.5 . A group of staff spoke to us and it was clear that staff are committed to caring for and improving the lives of the people who live at Conifer Lodge. There was evidence also to indicate that members of the team were supportive of each other. We were informed, however, that since the last inspection, staff morale has deteriorated due to changes in the role of the home Manager (see also Standard 37 of this inspection report) and changes in the management of the service, by the owners of Conifer Lodge. We were told by staff that although residents’ welfare has not been affected by this level of staff morale, staff considered that there was a risk to the quality Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 21 of care provided and risk to the quality of lives of the residents, should staff continue to have low morale. A requirement was carried forward following the last inspection as not all the required information had been obtained about staff. We examined two staff files and these files contained all the required information about the member of staff. This requirement has been met. Staff reported that they have attended training in some areas and documentation confirmed that this included care of the person with epilepsy and care of the person with challenging behaviours. The AQAA informed us also “All staff have undergone Timian Training (dealing with challenging behaviour)”. Arrangements for staff training have changed since the last inspection. According to the Manager a member of staff is the designated person to arrange training events from external providers. Documentation of staff training is manitained by this member of staff although this was not available in the home for inspection purposes. It is our expectation that this information is kept at the home for our inspections. Conifer Lodge DS0000062547.V353502.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 & 42 Quality in this outcome area is good. People benefit from a generally well-managed home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager, a Registered Mental Health Nurse, has carried out her responsibilities as a Registered Manager in a responsible way, such as informing us of any untoward events happening in the home and responding to the majority of the requirements made following the last inspection of Conifer Lodge in June 2006. She reported that, and staff confirmed this to be the case, that since our last inspection her role has changed. These changes have resulted in less time being made available to spend with staff and residents. (See also Standard 32 of this inspection report). Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 23 Surveys have been carried out asking people about their views of the home. These views included requests for people’s opinions about activities, staff and food. The Manager said that the results of these surveys have yet to be collated. We receive copies of regulation 26 reports. These reports are made by a manager, representing Ermine Care Limited, who visits the home and looks at the environment, staff files and asks people for their views of the home. The AQAA was detailed and identified areas that the home could improve upon. Records for temperatures of hot water, fire drills, fire alarms and emergency lighting were seen and these were satisfactory. Induction training records indicated that people had been shown the whereabouts of fire exits and fire fighting equipment. According to the AQAA 100 of catering staff and 70 of care staff have attended training in safe food handling. A requirement was made for all staff to attend fire training. Staff we spoke with confirmed that they all had attended fire drills but not all had attended training in how to operate fire fighting equipment or the prevention of fire. This was considered by staff as a result of the changes in staff training, since the last inspection. We are of the view that the evidence to suggest this requirement has been met was not sufficiently available to prove that there has been compliance with regulation 23(4)d) of the Care Homes Regulations 2001. We have carried this requirement forward, with a new timescale for action. Conifer Lodge DS0000062547.V353502.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 3 2 3 3 x 4 3 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 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 x 3 x 3 x x 2 x Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 25 YES 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 YA20 Regulation 13(2) Requirement The Registered Person must ensure the safe administration of medication with particular regard of service going on leave from the home. Timescale of 14/07/06 not met. Requirement carried forward with new timescale for action. The Registered Person must ensure that all staff attend training in fire safety matters. Timescale of 07/07/06 not met. Requirement carried forward with new timescale for action. Timescale for action 15/11/07 2. YA42 23(4)(d) 15/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Conifer Lodge DS0000062547.V353502.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cambridgeshire and Peterborough Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Conifer Lodge DS0000062547.V353502.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. 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