Care Home: Cheverton Lodge

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What the care home does well "Provides a welcoming and inclusive home" "The grounds are well maintained" "There is a good standard of hygiene both in terms of personal care and the physical environment" "There is a good sense of community and a number of activities for residents to enjoy." "Provides a high standard of care""Cheverton Lodge always strives to respect individuals privacy and dignity." "Staff always have the right skills and knowledge to meet people`s needs." "Staff respond well to comments and suggestions." The evidence that we had on file showed that this is a consistently well run home, where the interests of the people living there are paramount. The evidence we found during the visit supported this as did the views expressed above by some of the people living there and their relatives. Individuality, dignity, respect and personal choice are given a high priority. Staff were knowledgeable about the personal and health care needs of the people in their care as well their personal preferences. Although there is some evidence that staff should reflect on their practice more, but this will be discussed later in the summary. There is a welcoming atmosphere, homely environment and comfortable surroundings. Maintenance is ongoing. Assessment and care plans clearly set out how health and personal care tasks should be performed, with an emphasis on independence and, where possible, rehabilitation. The home provides intermediate beds where people are discharged from hospital in preparation for returning home. The home has a good reputation of supporting people to return to the community. There was a commitment to seeking the views of the people who lived at the home, and making improvements based on this. What has improved since the last inspection? Two requirements were set at the last inspection based on the need to ensure that staff receive regular supervision and an annual appraisal. The people managing the service have responded and staff receive supervision six times a year, a part of the supervision session is devoted to discussing any training and development needs and covers the philosophy of care. What the care home could do better: The service received some very positive feedback however one person did comment that sometimes staff did not always think about smaller things that can improve the quality of life for residents. These have been outlined in the main body of the report. Such areas need to be looked at as part of the discussion about the philosophy of care during supervision but also during team meetings and reviews. A requirement was set at the last inspection regarding using the bathrooms as storage areas. There has been no change to the situation. In generalbathrooms need to be pleasant and inviting places. A further requirement has been made with an extended timescale. CARE HOMES FOR OLDER PEOPLE Cheverton Lodge 30a Cheverton Road London N19 3AY Lead Inspector Pippa Canter Unannounced Inspection 31st August 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cheverton Lodge Address 30a Cheverton Road London N19 3AY 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) 020 7281 7040 020 7561 0928 cheverton@barchester.com Barchester Healthcare Homes Ltd Mary Rabitte Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (46), Physical disability (6) of places Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. For the provision of General Nursing Care for up to 46 Elderly People aged 60 and over. For the provision of general nursing care for 6 young physical disabled people aged 18 years and over The staffing notice Date of last inspection 29th August 2007 Brief Description of the Service: Cheverton Lodge is a fifty-two bedded care home, with nursing, located in Islington in a quiet residential road. It is owned by Barchester Healthcare and is registered for the provision of general nursing care for forty-six elderly people and six younger adults with physical disabilities. The home was opened in 1998 as a new build property. The young physically disabled unit is located on the ground floor and there are two further floors for older clients. All the homes bedrooms are single and most have en suite facilities. There are two passenger lifts. The home has an attractive garden that is easily accessible. Islington Council has a block contract with the care home for 30 beds. The level of fee is £669. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this key inspection was unannounced, and took place on a weekday from 10.00 to 17.00. One inspector carried it out. Prior to the site visit all information held at our office had been reviewed. This included reports that had been sent to us on a monthly basis, and about any incidents/changes that had occurred since our last visit. The manager had completed an Annual Quality Assurance Assessment (AQAA) which gave us information about the people living and working in the home as well as the home’s compliance with the key standards. We left questionnaires in the home for people who live there, for staff, relatives and professionals who visit the home. We received twenty-nine (29) replies. These were a mix of older people, younger adults, relatives, staff, care managers and health care professionals. Based on the above we developed an inspection plan. This concentrated on those key standards that we could not make a full judgement on without a site visit. During the visit we spoke to people living in the home, and examined five case files in depth. We talked to two of these people, and compared the planned care with the care they were actually receiving. We carried out a small sample audit of medication on each floor. We went round the home speaking to other people living in the home, to some staff and checking bathrooms and bedrooms We indirectly observed both nurses and care staff carrying out their duties. We have used the information collected from all sources to reach the judgments made in this report. At the end of the visit we discussed our findings with the manager and deputy manager, and a form will be sent with the draft report so they can let us know how they felt we had conducted the inspection. What the service does well: “Provides a welcoming and inclusive home” “The grounds are well maintained” “There is a good standard of hygiene both in terms of personal care and the physical environment” “There is a good sense of community and a number of activities for residents to enjoy.” “Provides a high standard of care” Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 6 “Cheverton Lodge always strives to respect individuals privacy and dignity.” “Staff always have the right skills and knowledge to meet people’s needs.” “Staff respond well to comments and suggestions.” The evidence that we had on file showed that this is a consistently well run home, where the interests of the people living there are paramount. The evidence we found during the visit supported this as did the views expressed above by some of the people living there and their relatives. Individuality, dignity, respect and personal choice are given a high priority. Staff were knowledgeable about the personal and health care needs of the people in their care as well their personal preferences. Although there is some evidence that staff should reflect on their practice more, but this will be discussed later in the summary. There is a welcoming atmosphere, homely environment and comfortable surroundings. Maintenance is ongoing. Assessment and care plans clearly set out how health and personal care tasks should be performed, with an emphasis on independence and, where possible, rehabilitation. The home provides intermediate beds where people are discharged from hospital in preparation for returning home. The home has a good reputation of supporting people to return to the community. There was a commitment to seeking the views of the people who lived at the home, and making improvements based on this. What has improved since the last inspection? What they could do better: The service received some very positive feedback however one person did comment that sometimes staff did not always think about smaller things that can improve the quality of life for residents. These have been outlined in the main body of the report. Such areas need to be looked at as part of the discussion about the philosophy of care during supervision but also during team meetings and reviews. A requirement was set at the last inspection regarding using the bathrooms as storage areas. There has been no change to the situation. In general Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 7 bathrooms need to be pleasant and inviting places. A further requirement has been made with an extended timescale. 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. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People moving into Cheverton Lodge can be assured that their needs, wishes and aspirations will be met. EVIDENCE: There is a comprehensive pre-admission assessment completed by competent people prior to any referral being accepted for a trial period. The manager or deputy will visit new referrals and supply them and their relatives and provide enough information for them to determine whether Cheverton Lodge is suitable. Staff confirmed that they are in receipt of all the relevant information necessary to develop a care plan. Islington Council has a block contract for 30 beds and the remaining referrals come mainly from other London Boroughs. The service provides interim/intermediate beds and discussion with the liaison nurse for the Primary Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 10 Care Trust clearly identifies that the care home will only accept people whose needs they can meet. A comment made was “Cheverton Lodge always ensures that the correct assessment information is gathered for planning care.” The home has a reputation of making every effort to support people to return home rather than become permanent residents. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is continuous assessment, care planning and review which makes sure that the personal and healthcare needs of the people living in the home are met EVIDENCE: A sample of five care plans were examined, which included looking at the daily recording for the previous three weeks. The care records were a sample from each floor and two from the ground floor. They included needs specific to racial origin, complex medical conditions, recent admissions and dementia. In each case we met with the person concerned but could not discuss their care with them in all cases. The relatives, health care professionals and care managers involved with each person was also asked for their feedback. A comparison was made between the care recorded in the records and the care being received by each resident. A sample audit was taken on each floor of the medication administration systems. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 12 The care plans were fund to comprehensive with important health and personal care needs being identified. The plans reflected both the needs and the wishes of each individual. Where additional assessments were indicated, such as manual handling, risk of pressures sores and nutritional risks, these had been carried out and were reflected in the care plans. Samples of falls risk assessments and incontinence were also available. From observation and discussion with people using the service is was clear that service delivery matched the care plans. Comment from a health care professionals confirmed the following “Visual and written evidence is available to reassure me that individual health care needs are always monitored.” “Individuals are being discharged from hospital earlier therefore an increase of people with complex needs. Cheverton Lodge have intermediate care/interim beds, once again, different demands, they are flexible in meeting people’s needs.” As from previous inspections the care records clearly show referrals to and the involvement of other health care professionals. The records show that the registered nurses are responsive to changes in condition or behaviour of people living in the home and have made referrals to the General Practitioner (GP). A GP describes the home as a “Welcoming and pleasant environment in which to consult.” Another comment was “Very devoted care staff”. There is clear evidence of collaborative care with other health care professionals. A sample audit was taken on each floor relating to the handling and control of medication. This was judged to be managed very well and this is a viewpoint echoed by other health care professionals including the General Practitioners. The service has a robust policy and procedure for the ordering receipt, storage, administration and disposal of medication. This is known to the nursing staff who are responsible for the administration of medication and underpins their practice. Observation on the day of the site visit, discussion with staff, feedback from people using the service and the examination of the care records confirmed that staff respect the privacy and dignity of the people they look after. A comment from a care manager was “Cheverton Lodge always strives to respect individual’s privacy and dignity.” Feedback from residents was positive and they confirmed that staff are sensitive when they needed help with personal care and that gender specific care was given. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Cheverton Lodge supports people to live the life they choose respecting their choices and individuality. EVIDENCE: All five care plans seen were comprehensive and included wishes and preferences. An activities organiser is in post and a programme is available. The service has access to a mini bus. Feedback from the people living in the home confirmed that they have access to a varied programme with activities taking place in the home as well as in the community. One resident confirmed that they have been on trips to the cinema and attended a concert. On the day of the inspection, there was an afternoon outing to a local pub. Throughout the inspection, residents were seen occupying themselves by reading, watching television or listening to music in their own rooms. Those spoken to said that they were satisfied with the level and variety of activity provided. They all confirmed that they were given the choice to attend and felt no pressure to be involved. People living in the home have contact with their respective churches and services are held in the home. A comment received Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 14 was “There is a good sense of community and a number of activities for residents to enjoy.” Generally people felt that they had control over their lives and there was praise for the staff in supporting people to be independent. However there was feedback from one person, which is valid to include here and the implications of which should be discussed as part of supervision, team meetings and reviews. The comments were as follows: “Staff should think more carefully about the smaller things that can improve the quality of life for residents e.g. my mother is put to bed often she is unable to reach articles on her bed side tray, such things as TV controls, water, call bell. She finds it demoralising and leaves her frustrated.” “Better care should be taken with resident’s clothes. I often find my mother’s clothes pushed onto the shelf in the wardrobe, which in turn means she is dressed in creased clothes, which she finds upsetting.” A recommendation has been made. Visitors said that they are made to feel welcome in the home. Some said that this is a strength with comments such as “Provides a welcoming and inclusive home.” The manager organises relative and residents meetings in order to listen and take on board their views. Relatives find the staff in the home to be responsive to suggestions or comments. The menus were noted to be varied and nutritionally balanced. The menu reflected peoples’ choices as meat eaters, vegetarians and varying cultural tastes. The food served at the lunchtime meal looked appetising and peoples’ preferences were being served. Meal times were seen to be relaxed and social events and where people required assistance to eat and drink this was done in a sensitive manner. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are fully protected by the approach to complaints, incidents and allegations. EVIDENCE: Complaints, incidents and accidents are being recorded. These records were cross-referenced with the care records of the people being case tracked. The accident reports were compared with the Regulation 37 notifications sent by the service since the last inspection. The home has a comprehensive complaint’s policy and procedure. Feedback clearly identifies that this is known to both staff, people living in the home and their relatives. Comments received were all positive about how staff are responsive to comments and/or suggestions as well respond appropriately to any concerns raised. Overall residents said that they felt safe in the home. The service has a robust policy and procedure on adult protection, which is linked to local authority guidance. Staff have received training on adult protection and showed that they understood their role and responsibilities in this area for the safety and protection of the service users. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who reside in the home live in comfortable, homely and clean surroundings. EVIDENCE: The home was clean and well presented on the day of the inspection. Comments from people associated with the home were as follows: “Provides a welcoming and inclusive home” “The grounds are well maintained” “There is a good standard of hygiene both in terms of personal care and the physical environment.” “Provide comfortable living accommodation”. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 17 The rooms of the service users being case tracked showed that individuals had been able to personalise their private space. Individual liked their bedrooms and in particular were pleased to have an ensuite. All the rooms were clean and there were no odours detected. Chemicals were being stored correctly and COSHH assessments and data sheets were in place. There was hand cleanser and protective clothing available in all required areas. Aids and equipment were available to meet the assessed needs of the people living in the care home. The stock available was in reasonable condition although the manager acknowledges that an area for improvement is the general replacement of equipment to ensure that health and safety is maintained. There is a rolling programme of refurbishment as the care home has a full time maintenance person who is responsible for day to day events. The home is also supported by the providers estate managers and interior design team. A requirement was set at the last inspection as bathrooms were used as storage areas. The home is short of storage and the large bathrooms become storage facilities. This would not provide a congenial environment for having an assisted bath. However there does have an impact on resident’s choice and efforts need to be made to make the bathrooms more appealing generally. This is requirement 1. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team has the skills, knowledge and appropriate attitudes to meet the needs of the people admitted to their care. Staff assist people to reach their full potential to enable them to return home following a stay in hospital. EVIDENCE: Staff were described as “very caring”, “well-motivated”, “reliable and approachable”. Feedback from the staff group showed that they found working in the home a very positive experience and were proud of the care they provided. Nine staff returned surveys and all confirmed that the employer carried out checks such as CRB and references before they started work. This has been corroborated at previous inspections. The provider has a thorough and robust recruitment and selection process. Staff confirmed that the induction process covered what they needed to know about their role and repsonsibilities. They are provided with training that is relevant to their role, helps them to understand and meet the individual needs of the service users (including disability, gender, age, race, ethncity, faith and sexual orientation) and keeps them up-to-date with new ways of working. A care maanger commented that the service is flexible about meeting needs even complex needs. A cooment was made that people who are admiited for intermediate care are more likely to return home such is the level of care and support given by staff in the home. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 19 A requirement was made that the home should ensure that staff have regular supervisions nad apperaisals. It is clear from the evidence that line managers are regularly meeting with staff to give support and discuss how they are working. Staff are confident with the complaints procedure and know how to respond to a service user and/or a relative if they have concens about the home. This was cooroboarted by a relative who commented that staff listen to suggestions and comments. Staff generally found the lines of communication and accountability to be effective and efficient. Feedback identifies that the staffing levels were sufficient to meet the individual needs of the people they looked after. Comments on the staff surveys included: “Very friendly staff to everyone using the service” “We are trained to treat each service user as an individual.” Provide high quality care.” “Provide a five star dining experience” “Train the staff” “They provide me with different training and classes” “The service does everything well”. “The service cannot do anything better.” “Management is available for support, consultation at all times” Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality assurance are effective and the service is proactive in addressing quality issues within the home ensuring that the home is being managed in the best interests of the people who live there. EVIDENCE: The manager completed and returned an Annual Quality Assurance Assessment (AQAA) prior to the inspection. The information within the AQAA and further discussions with the manager during the site visit demonstrated a good level of awareness of the strengths of the service and the areas where improvements are necessary. A comment received about the management of the home was: Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 21 “The manager and deputy are professional in their work, approachable and they do make a difference to people’s lives and the very elderly population.” The judgements in preceding sections of this report have contributed to the judgement in this outcome area. The care home has a welcoming environment and promotes an open and transparent style of management. The provider has introduced the role of the Compliance Officer who undertakes audits in line with the National Minimum Standards and Care Home Regulations. This means that there is continuous monitoring of the quality of the service. People using the service are protected by the policies and procedures and their feedback feeds into any improvements to the service. There are effective systems in place to manage financial arrangements within the home. The home’s Public Liability Insurance certificate is on display and is current. Staff are supported through professional and personal development although a comment from a health care professional was that the service could improve by providing “ongoing training and support for all who here (in the home). The inspector will feed this back to the manager as this is an area not reflected in the remainder of the feedback which was very positive. A sample of health and safety records were looked at. These confirmed that the home is being managed responsibly with essential checks being made. The provider monitors health and safety in the home. There are robust procedures in place to monitor compliance. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP38 Regulation 13(4) Requirement The registered person must ensure that all bathrooms are kept clear and not used as storage space. Timescale for action 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP14 Good Practice Recommendations It is strongly recommended that staff are supported to reflect on their practice to ensure that they maximise the quality of life for people in their care. Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Cheverton Lodge DS0000069394.V351558.R01.S.doc Version 5.2 Page 25 - 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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