Inspection on 15/05/07 for Ashlea Lodge Residential Home

This inspection was carried out on 15th May 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 but made no statutory requirements on the home.

Other inspections for this house

Ashlea Lodge Residential Home 02/11/09

Ashlea Lodge Residential Home 29/07/09

Ashlea Lodge Residential Home 12/05/09

Ashlea Lodge Residential Home 06/03/09

Ashlea Lodge Residential Home 06/07/06

Ashlea Lodge Residential Home 29/11/05

Ashlea Lodge Residential Home 03/06/05

Ashlea Lodge Residential Home 13/12/04

Ashlea Lodge Residential Home 22/07/04

Ashlea Lodge Residential Home 12/03/04

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

CARE HOMES FOR OLDER PEOPLE Ashlea Lodge Residential Home Hylton Road Millfield Sunderland SR4 7AB Lead Inspector Sam Doku Unannounced Inspection 15th May 2007 06:30 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 Ashlea Lodge Residential Home DS0000034296.V338152.R02.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. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashlea Lodge Residential Home Address Hylton Road Millfield Sunderland SR4 7AB 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) 0191 510 9405 0191 510 9406 ashlea.lodge@btconnect.com Winnie Care Limited Mrs Maureen Curry Care Home 40 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (11), Old age, not falling within any other of places category (40), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (5) Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2006 Brief Description of the Service: Ashlea Lodge is a two-storey building, which has been specifically designed to provide personal care for older people who may have a variety of needs, including people who have dementia. The layout of the building allows for the home to be divided into two separate units and each contains a lounge, dining room, kitchen, bathroom, toilets and en suite bedrooms. A garden, which is accessible to people who use a wheelchair is at the rear of the building and there is a car park at the front. The home is located close to St Marks Church and a GPs surgery, both of which are easily accessed. The metro line has a station within walking distance from the home. In addition, there is a regular bus service, which stops opposite the home. Ashlea Lodge is situated relatively close to a shopping area, which has a post office, grocers and public houses. The home is registered to admit 40 people who may have physical disabilities or who may have dementia type illness. The home is owned by Winnie Care Limited. The scale of charges for the home is £372.00 to £387.00 per week. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted in one day and involved one inspector. The visit to the home started at 6:30 in the morning specifically to observe the morning activities in the home, including how service users are supported, first thing in the morning, to get ready. The inspector spoke with the night staff about the night routines and the support they give to service users. The night staff were asked about their understanding of the fire procedures in the home and they showed good understanding of the procedure. The home is well equipped with aids and adaptations suited to the client group’s age and lifestyle preferences. The home has plenty of space in all areas. It is popular with service users and their families, and there is a great deal of involvement by the local community. This inspection process involved talking to service users, visitors, sitting in the lounge and observing staff interaction with the service users, discussions with the Manager and care staff, tour of the house, examination of health and safety records and service users’ personal file including care plans. Staff files were also examined to make sure the home was following the proper recruitment procedures. The atmosphere in the home was calm and peaceful and service users and relatives were able to express their views freely to the inspector. What the service does well: The home has maintained good working practices in ensuring that all parts of the home remain clean and maintained to good standards. The home continues to benefit from a refurbishment programme with re-decorations, new chairs, beddings and curtains for the home. These are tastefully matched, providing pleasant environment for the service users. The home provides good and pleasant dining areas, which are pleasantly furnished and provide beautiful and relaxing setting for the service users. Service users enjoy their meals in a relaxed environment and the meals are nicely presented. The home continues to positively encourages and assist service users to use local facilities, thus maintaining their links with the local community. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 6 There have been good improvements to the care plans, including the details of care to be provided to enable staff to provide a consistent service to the service users. The home provides good training for the staff. Sixteen of the staff have acquired NVQ Level 2 and remaining staff are currently undertaking the NVQ training in care. What has improved since the last inspection? What they could do better: The fluid balanced charts and turn sheets for one service user have not been dated and therefore it was not possible to determine if the person was receiving the care that she was meant to receive. Staff must ensure that the records relating to personal details about the service users are fully completed. For example, in one file the details of the service user were not fully completed. In another case the assessment that was carried out by the home did not state who carried out the assessment and also it was not dated. In some of the care plans, the social assessment part of the document had not been fully completed. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 7 A number of staff expressed concerns about families working in the home and the negative impact that this is having on staff moral. Some staff cited examples where this is having negative effect on the quality of care provided. Security I the home must be reviewed. The front door was left unlocked at 6:30 in the morning when the inspector arrived in the home. He entered the home and was in the reception area for five minutes before he encountered a staff member. Staff induction programme must be fully implemented and documents relating to it must be kept in the home. The service user guide should be reviewed to reflect the current staffing structure of the home and also to update the information relating to the Commission for Social Care Inspection. 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. Ashlea Lodge Residential Home DS0000034296.V338152.R02.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 Ashlea Lodge Residential Home DS0000034296.V338152.R02.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): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user guide and the statement of purpose provide useful information about the home and the service provided. This allows prospective service users to gain information about the home in assisting them to make a decision about coming to live at Ashlea Lodge. The home receives full assessments from a social worker before admissions are arranged. The home also carries out an assessment of needs that complements the social worker’s assessment. This enables the home to determine the care needs of the person and formulate care plans to meet those needs, thus meeting the needs of the service users. The home continues to actively encourage prospective service users to visit the home, meet with staff and other service users before deciding on whether or not to choose to live at Ashlea Lodge. This provides the opportunity for prospective service users to make informed decision about their choice of home. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 10 EVIDENCE: There is a service user guide, which is also available in large print. This is readily available in the home and provides good information about the home and the service provided. The guide would however, need to be reviewed as the information do not reflect the current management structure of the home and also information about the Commission for Social Care Inspection is not up to date. The home maintains their policy of receiving social work assessment or carry out their own before admission is arranged. Service users files show that the home adheres to its policy. This provides assurance to the service users, their relative and significant others that people’s care needs are properly assessed and the home has demonstrated that it has the resources and the skills to provide the service for the individual. Service users and relatives confirmed that before they chose Ashlea Lodge they were confident that the home could meet their needs or those of their loved ones. The manager confirmed that it has always been the policy of the home to invite prospective service users to visit the home to meet with other service users and staff. The service user guide and statements from the service users confirmed this arrangement. Service users described their experience of visiting the home with the families before deciding on making the final decision to come and live at Ashlea Lodge. A number of service users and relatives said they found the opportunity to visit the home beforehand very useful. Ashlea Lodge Residential Home DS0000034296.V338152.R02.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. Care plans provide detailed action plan on how staff should meet the needs of the service users. This ensures that staff carry out care tasks in a consistent manner for the benefit of the service users. Staff respect the right of the service users and engage in practices that promote their rights and dignity. Suitable arrangements ensure that medication systems are safe and appropriate and service users receive appropriate medication thus promoting their health and welfare. EVIDENCE: Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 12 There are suitable arrangements in place for meeting the care needs of the service users. There is evidence of visits to GPs, hospital out-patient appointments, chiropody treatment, opticians, dentists and other healthcare professionals. Service users confirmed that there are suitable arrangements in place for meeting their healthcare needs, and described recent medical or healthcare appointments and treatments they have received. Families also confirmed that the healthcare needs of their relatives are fully met thus promoting their health and welfare. One service user who requires regular medical and nursing attention was well looked after in the home. Records show involvement of her GP and the district nurse who are contributing to her care. However, the records relating to her fluid intake and turning in bed were not properly maintained. Service user care plans provide good assessment information about the care needs of the individuals and identified their health, personal and social care needs. However, in some cases, the social care need section of the plan have not been fully completed thus loosing useful information about the recreational and social care needs of the individuals. Where risks have been identified, suitable risk assessments have been carried and risk management plans put in place to promote the health and welfare of the individual. An example of this is risk of falls and plans are developed to ensure safe environment for the service users and others through proper handling. Inspection of the arrangements for the storage, ordering, receipt, administration and disposal of medicines was carried out and were satisfactory. The medicine administration records (MAR) were generally well kept with clear records made. There is good control system in place, which makes it easier to carry out an audit trail. Suitable arrangements are in place for the appropriate disposal of medicines including controlled drugs. Drug returns records are kept details of those medicines that have been returned to the chemist. Ashlea Lodge Residential Home DS0000034296.V338152.R02.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. Practices in the home enable service users to exercise choice and to maintain lifestyle that is similar to what they are used to. This promotes healthy lifestyle for them. The service users are supported to maintain contacts with their families, friends and the local community. Such support has enabled the service users to continue to maintain close relationship with their loved ones and the community from which they come from. The service users receive nutritious diet, which contributes to their health and wellbeing. EVIDENCE: Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 14 Service users confirmed that the staff continue to support them to engage with the local community. Individual service users described arrangement and support given them to visit local shop and visit places where they meet their old friends. The service users regularly use community facilities such as the local shops, visits to the hairdresser, GP appointments and local church. Staff commented that the local Salvation Army continue to visits the home regularly to talk to the service users. The local vicar also continues to visit the home on regular basis to offer church service and communion to those who wish to have it. This ensures that the spiritual and religious needs of the individuals are met. staff were observed to be engaging the service users in activities that were stimulating and service users appeared to be enjoying the experience. The manager confirmed that this is organised on a regular basis and service users enjoy the experience. Service users also commented on the activities organised for them and indicated that they always look forward to these. Service users and staff confirmed that service users have regular contacts with families and friends. Visiting relatives confirmed that staff regularly contact them if there are changes in the conditions of their relatives, and were extremely grateful for the constant update through telephones calls on the condition of their relatives. The relatives were happy with the flexible visiting times, which enable them to visit at times convenient to them. This ensures that service users are in regular contact with the community and their relatives. Past menus show that the home provides homely and nutritious meals for the service users. Service users were very complimentary of the food and the choice of meals provided in the home. Meals are served in pleasant settings and the service users are given sufficient time to eat their meals in peace and tranquillity. Those who require assistance with their meals received such assistance from the care staff in a discrete way that promoted their dignity and self-respect. Ashlea Lodge Residential Home DS0000034296.V338152.R02.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, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear, easy to understand and accessible to the service users and relatives. This provides the opportunity for service users or relatives to raise concerns and in so doing exercising their rights. Suitable arrangements are in place, which ensure that service users are protected from all forms of abuse and to protect their rights. This is reflected in the training and practices within the home. EVIDENCE: The written complaints procedure is displayed in the home for the benefit of the service users and visitors. The service user guide also has summary of the complaints procedure, thus making it accessible to both service users and their relatives. Service users stated that they are aware of the complaints procedure and would have no problems in raising any concerns with the manager or any member of staff. Individuals said if they have any concerns they feel confident that the manager would address their concerns Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 16 satisfactorily. One service user cited an example of a concern he raised with the manager and said he was satisfied with the ways it was addressed. Staff records show that suitable training on the protection of vulnerable adults (POVA) has been provided for the majority of the staff working in the home. The home’s complaints procedure and the protection of vulnerable adults procedures are in line with the City of Sunderland complaint and adult protection procedures. Staff have good understanding of the POVA procedures and an awareness of the need to protect service users from all forms of abuse. All staff have had CRB checks and staff files now contain application forms, references, ID checks or CRB check. This aspect of the home’s administrative procedures have greatly improved for the benefit of protecting service users from abuse from people who would otherwise be considered as not suitable to work with vulnerable people. Service users commented that they feel their rights are protected in the home. Practices observed during the inspection would indicate that the service users rights are protected. One service user spoke about recent local election and how he was able to exercise his right to vote. Others said they received postal votes. Some said they voted, other said they did not bother to vote through choice. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 17 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, 20, 22, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides accommodation of a good standard. It is a safe, clean and comfortable environment, and promotes the service users’ privacy, independence and self-esteem. EVIDENCE: The positive comments made in the last inspection report about the home have been maintained and the positive comments are repeated here. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 18 The home designed to accommodate older people, some of whom may have mobility problems. Access into and within the home is good and meets the needs of those service users who have mobility difficulties or have use of walking aids such zimmer frames or wheelchairs. There is specialist bathing facilities to promote independent use by those who are capable of doing so. All the bedrooms and toilets have suitable lock on the doors. This provides the opportunity for service users to remain independent and to enjoy good levels of privacy. The home has benefited from continued re-decoration programme. New beddings, furniture and curtains have been purchased providing a warm, pleasant and comfortable environment for the service users. The dinning rooms are beautifully furnished and set which enhances the self-esteem of the service users. The home is close to local shops, other amenities, and to local transport routes. Staff support service users to visit the local shops and access local amenities. Those service users who have had such support expressed their gratitude for the opportunity to continue to visit the local facilities. Window restrictors have been fixed to all windows and all radiators have suitable coverings which ensures security and safety for the service users. Checks of hot water at randomly selected bathrooms confirmed that hot water did not exceed 43°c. thus protecting the service from accidental injuries. The home has written policies and procedures relating to safe handling of hazardous materials for staff to follow. The manager indicated that staff have had training in health and safety, infection control and food hygiene. The home was noted to be clean and free from offensive odour. This enhances the self-esteem of the service users. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff are deployed in sufficient numbers and with varied experiences to meet the needs of the service users. Suitable arrangements for staff training and supervision are in place, which ensures that staff are reasonably equipped to provide good quality service that benefits the service users. EVIDENCE: The home has maintained appropriate staffing levels which ensure that care needs of the service users are met. The rotas show that sometime additional staff is provided on night shift and also on day shifts if this is seen by the registered manager as necessary. Staff confirmed these arrangements and feel that this enables them to provide a service that meets the needs of the people they care for. Service users and relatives also indicated that there are always sufficient staff on duty to meet the needs of service users. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 20 The home has maintained its programme for are staff to achieve NVQ Level 2 or above. The manager confirmed that 16 have NVQ level II and the rest are currently undertaking such training. The last inspection report commented on the issue of families working together and the potential for this compromising the whistle blowing policy and care practices. This issue remains outstanding and there are obvious concerns amongst staff about the impact this is having on staff moral and the negative impact this could have on service delivery. The company needs to be assured and confident that current situation does not adversely affect the care people receive. The training log shows that staff training in moving and handling, first aid, fire safety training, food hygiene, dementia awareness and protection of vulnerable adults awareness training is up-to-date. The company continues to update staff on all the statutory training and other training that relates to promoting good quality care. Such training protects the welfare and safety of the service users. Staff records show that there have been improvements in the recruitment process. This ensures that the service users are protected from possible abuse from people who would be deemed as not suitable to work with vulnerable people. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager generally runs the home for the benefit of the service users. Service users feel empowered, which has enhanced their self-esteem. The home has good administrative systems in place for managing the service users monies. This protects the service users from financial abuse. The detailed organisational policies and procedures on health, safety and welfare are adhered to by the staff, which protects the welfare of the service users. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 22 EVIDENCE: The manager has long experience of working in a care home and has had good management experience in care settings. She has acquired the registered managers award. This training has further enhanced her skills for the benefit of the service and the service users. Staff, service users and relatives described the manager as efficient and very caring. One staff member described how the manager has managed to bring some stability to the home. Staff feel that she runs the service for the benefit of the service users and has positive relations with them, relatives and service users. The manager has been able to establish her style of management in the home and staff have been working with her more positively. Staff receive regular supervision from the manager. Staff confirmed that individual supervision arrangements are taking place and they find the exercise very helpful as they feel it gives them the opportunity to discuss their training and development and also to discuss matters personal to them with the manager. The home has detailed Health and Safety policies. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). The manager stated that staff have had training in food hygiene, fire precaution and first aid. Such training ensures the health and safety of the service users and the staff. All portable appliances have been tested. A record is maintained of monthly water temperature tests in the home. There is evidence of regular servicing of fire equipment, gas and electrical appliances being carried out by the Company. All the servicing records that were examined were up to date. These included fire-fighting equipments, servicing of hoists, lift servicing, water treatment, electrical installation and gas servicing. Up to date servicing and maintenance of these services and equipments ensure a safe environment for the service users and the staff who work there. A record is maintained for those service users for whom the home handles their personal allowances. Individual purchases are accounted for through receipt and details record of items bought on behalf of the service users. These indicate that the service users monies are safe and managed well, thus preventing any possible financial abuse. Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Fluid balance and turn chart must be kept up to date to reflect the care that a service user is receiving. These charts were not dated and not fully completed by the care staff. Assessment forms must be fully completed to include the social assessment section so that a complete picture of the service user can be obtained. This must also include the name of the person carrying out the assessment. The security in the home must be reviewed. The front door was unlocked in the very early hours of the morning when the door should have been kept locked. Staff induction programme must be fully implemented and all new staff should receive induction training. This must be documented and retained on the individual’s file. The home must be managed in a way that would ensure that there are no potential situations that would undermine the company’s DS0000034296.V338152.R02.S.doc Timescale for action 30/07/07 2 OP7 14(1)(a) 30/07/07 4 OP19 12(1)(a) 30/06/07 5 OP30 18(c)(i) 30/06/07 5. OP32 12(5)(a)( b) 01/08/07 Ashlea Lodge Residential Home Version 5.2 Page 25 policy on whistle blowing. 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 Ashlea Lodge Residential Home DS0000034296.V338152.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Ashlea Lodge Residential Home DS0000034296.V338152.R02.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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