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Inspection on 04/01/06 for Ashley Lodge Residential and Nursing Home

Also see our care home review for Ashley Lodge Residential and Nursing Home for more information

This inspection was carried out on 4th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The standard of care in the home was good and was based on comprehensive assessments of the needs of both potential existing residents. These resulted in plans of care that ensured that residents received the individualised support and help that they required. The homes approach to care was also reflected in the links it had developed with a local hospice to ensure that residents who were terminally ill received appropriate attention. The home promoted the right of residents to make choices for themselves and exercise personal autonomy including their participation in the civic process. Residents described the home`s bedroom accommodation positively and all bedrooms seen were well maintained and furnished and equipped. The home`s manager was experienced and both the home`s staff team and the residents valued her personal qualities and abilities. The staff team were well motivated. Management systems and procedures in the home worked well including, managing medication, staff training and professional development , and health and safety.

What has improved since the last inspection?

The home had implemented a new system for managing the care of terminally ill residents and the staff were enthusiastic about the approach that had been adopted and in particular the clear documentation that enabled them to ensure that all aspects of a dying residents needs were addressed.

What the care home could do better:

There were no matters of concern identified during this inspection.

CARE HOMES FOR OLDER PEOPLE Ashley Lodge Residential and Nursing Home Golden Hill, Ashley Lane Ashley New Milton Hampshire BH25 5AH Lead Inspector Tim Inkson Unannounced Inspection 4th January 2006 09:30 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 Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 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. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ashley Lodge Residential and Nursing Home Address Golden Hill, Ashley Lane Ashley New Milton Hampshire BH25 5AH 01425 611334 01425 619320 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) BUPA Care Homes Limited Mrs Joanna Dunbar Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (10), Physical disability of places over 65 years of age (50), Terminally ill (5), Terminally ill over 65 years of age (50) Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. A maximum of 10 service users between the ages of 50-64 years in the category of PD may be accommodated at any one time. A maximum of 5 service users between the ages of 50-64 years in the category of TI may be accommodated at any one time. Ten service users may be accommodated at any one time who are in need of personal care only. A maximum of 10 service users between the ages of 50-64 years may be accommodated at any one time. 15th August 2005 Date of last inspection Brief Description of the Service: Ashley Lodge Nursing and Residential Home comprises two separate buildings/houses on one site. They are respectively known as Ashton House and Milton House. The home is owned and managed by BUPA Care Homes Limited (the organisation), a not-for-profit company. Both buildings stand in pleasant and well-maintained grounds, offering pleasant views from many bedrooms. The home is located in Ashley, within close proximity of New Milton, a small country town that offers a range of amenities including library, places of worship, a leisure centre, shops and restaurants. The accommodation at Ashley Lodge compromises 44 single rooms and 3 double rooms; 29 of the rooms provide en suite facilities. Ashton House can accommodate 28 and Milton House 22 residents. Both houses provide accommodation on two floors and have passenger lifts providing access to their first floor accommodation. Both house also have their own communal rooms i.e. lounges and dining rooms. There is one laundry and one main kitchen and both are located in with the homes main office in Ashton House. Meals are conveyed to Milton House in a heated trolley. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two that must be made of the home during the 12-month period beginning on 1st April 2005. It started at 09:30 hours and finished at 15:35 hours. The inspection procedure included viewing a sample of some bedrooms (9), an examination of documents and records, observation of staff practices where this was possible without being intrusive and discussion with residents (9) and staff (6). At the time of the inspection the home was accommodating 34 residents, with 14 in Ashton House and 20 in Milton House and of these 6 were male and 28 were female and their ages ranged from 54 to 101 years and 29 were receiving nursing care. No resident was from a minority ethnic group. The home’s head of care manager was present during the day and available to provide assistance and information when required and the registered was also available for some of the time. The number of vacancies that the home had (16) at the time of the inspection was due to the fact that work was due to begin on the construction of a large extension to enable the number of residents accommodated at the home to eventually be increased. This would also result in existing accommodation being refurbished and improved. Consequently the number of residents accommodated in the home had been reduced because of the scale of the work and level of disturbance that would result from the construction work. What the service does well: The standard of care in the home was good and was based on comprehensive assessments of the needs of both potential existing residents. These resulted in plans of care that ensured that residents received the individualised support and help that they required. The homes approach to care was also reflected in the links it had developed with a local hospice to ensure that residents who were terminally ill received appropriate attention. The home promoted the right of residents to make choices for themselves and exercise personal autonomy including their participation in the civic process. Residents described the home’s bedroom accommodation positively and all bedrooms seen were well maintained and furnished and equipped. The home’s manager was experienced and both the home’s staff team and the residents valued her personal qualities and abilities. The staff team were well motivated. Management systems and procedures in the home worked well including, managing medication, staff training and professional development , and health and safety. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 7 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 Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home’s admission procedures included good assessments of the needs of potential residents before they moved into the home to ensure that the home could provide the care and support that individuals required. EVIDENCE: The home had written policies and procedures concerned with the admission of new residents to the home and these referred to the importance of ascertaining the help required by potential residents before they moved into the home. The records of 4 residents were examined and these included copies of detailed assessments that the home had arranged of the needs of the individuals concerned. On this occasion as at the last two inspections of the home on 12th January 2005 and 15th August 2005 it was apparent from discussion with residents and the documents examined that the needs of potential residents were identified before the persons moved into the home. • “Someone from the home came to see me before I moved in”. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 9 It was also evident from the records examined that the home wrote to potential residents before they moved into the home informing them that the home could meet their assessed needs. The pre-admission assessments were complemented by more thorough and comprehensive assessments of a resident’s needs when they actually moved into the home. There was documentary evidence that assessments of residents needs were reviewed regularly and revised as necessary when an individual’s circumstances had changed. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 11 There were good plans of care in place that ensured that residents received the help and support that they needed. Good procedures and systems for ensuring that medicines were managed and administered safely were in place and death and dying was managed sensitively by the home. EVIDENCE: On this occasion as at the last two inspection of the home on 12th January 2005 and 15th August 2005, a sample of the care plans of residents were examined (4). The documents were detailed and the plans were based on the assessments the home carried out in order to identify what help individuals needed (see pages 9 and 10). The plans set out clearly the actions staff had to take and what specialist equipment was needed to provide the support and assistance each person required. Observation and discussion with the residents concerned, confirmed that individuals received the help they needed and that the equipment was in place as set out in their plans of care. There was evidence from both the documentation that was readily available in the individual’s bedroom and discussion with residents concerned that individuals and/or their representatives had been involved in developing the plans and agreed with the contents. • “What happens to me goes in there”. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 11 • “I Know all about the plan, I call it their homework as they have to write something in it everyday”. All nursing and care staff spoken to were fully aware of the contents of the care plans that were sampled and the assistance that the individuals concerned required. The care plans documents included assessments of the potential risks to residents of among other things, pressure sores, malnutrition, and falls. Strategies for eliminating or reducing the risk of harm had been identified and implemented e.g. pressure-relieving aids were in place. There was documentary evidence that care plans were evaluated and reviewed regularly. The home had written policies and procedures concerned with the management and administration of medication. A range of reference material about medication was readily available including copies of the British National Formulary (BNF). Medication was kept in a locked rooms and also in 2 locked and secured medicine trolleys, and where required in a medical refrigerator. Controlled drugs were stored securely and in an appropriate metal locked cabinets. The home used a monitored dosage system that consisted mainly of medicines that were enclosed in blister packs and supplied by a local pharmacist. Some medicines that could not be put into the blister pack system were dispensed from their original containers. Registered nurses were responsible for the management and administration of medication and copies of their specimen signatures were available. Records were kept of the ordering, receipt, administration and the disposal of medicines and these were accurate and up to date. The home had implemented new methods for the disposal of unwanted and unused medicines. This had arisen as a result of recent changes in the National Health Service contract for community pharmacists and to ensure compliance with legislation about the disposal of industrial waste. The home’s written medication procedures referred to above included this. Good practice noted during the inspection included the dating of bottles/containers of liquid medicines when they were opened and monitoring of the temperature of the medical refrigerators to ensure that they were working effectively. There was written guidance and policies as well as extensive guidance material available concerned with managing the death of residents. The home had worked closely with a local hospice and implemented new documentation based on best practice that was initially developed in Liverpool and known as the “Liverpool Care Pathway”. Specific, comprehensive and clear documented plans were used for terminally ill residents when a multi-professional team had agreed that an individual’s death would occur within a few days. The plans ensured that all matters that should ensure a “good death” were included in the plan for the person Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 12 concerned e.g. involvement of family/friends; communication and insight/understanding; spiritual needs; pain control; personal hygiene; pressure care; psychological support of individual and family/friends; practical needs if family/friends; and procedures following death. Health care assistants and registered nurses spoken to said that they received training and support from the local hospice in palliative care matters and that the new care pathway was “very good”” because “it takes away the shall I or shan’t I questions, you just follow the document and it is brilliant”. The records of a resident that had recently died were examined and it was apparent from notes that had been kept that the comfort and dignity of the individual and the support of their relatives had been paramount. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The home had good procedures in place for ensuring residents could exercise self-determination. EVIDENCE: The home had written information readily available in a pack that it gave to existing and potential residents that included the home’s Service Users Guide. The information made reference the home’s philosophy and to the rights of residents to make their own choices, act independently and enjoy the same freedoms as any person. There was information available in the entrance hall of the home about organisations that could provide independent advice or advocacy for residents and or their relatives/representatives. The home’s written policies and procedures included one concerned with the management of residents monies and the home’s licence agreement/terms and conditions of accommodation issued to all residents included reference to the ability of resident to bring into the home, “items of furniture and equipment as agreed with the home’s manager”. Some residents spoken to had taken advantage of the opportunity to furnish and personalise their bedroom accommodation while others said that they were not concerned. • “That chest of drawers, the video and the television are mine”. • “The trolley, chair and all those pictures are mine”. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 14 “Some people have brought their own furniture, but I could not be bothered” Two residents spoken to continued to manage their own financial affairs. • “I look after my own money, I pay everything by cheque or credit card, I do it all myself. Mind you if I go senile my daughter has power of attorney”. • “I am very independent, I pay my fees by cheque, I am actually “struggling” with my monthly statement that I get from the home at the moment”. Another was clearly content to have handed the responsibility over to a relative. • “My daughter looks after my money and it’s quite a relief as I can’t cope with it now”. The home had written policies and procedures about “Confidentiality” and “Access to Records”. The latter stated among other things that residents had the right to access their own records. Individuals care plans were readily available to them in their own bedrooms and all bedrooms could be locked. All other sensitive information about residents was kept secure in locked filing cabinets. Comments from residents about their ability to exercise choices included the following: • • • • “If I don’t want to do something I won’t do it”. “I decide what I am going to do and when and where, perhaps not if I wanted to go to London tomorrow, but you know what I mean. I am a late bird and I watch TV a lot these days”. “We can choose to do what we want, we can please ourselves and do what we like, go to bed and get up when we want, we are never hurried”. “We don’t have to join in activities. I prefer my own company and I enjoy watching TV. I go through the magazine to see what is on and mark the programmes I want to see, I turn my light out at about 10:30 p.m.”. • Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 There were good procedures in place to ensure that residents could exercise their civic rights. EVIDENCE: Several residents spoken to confirmed that they were able to vote in local and general elections. • “I vote by post, I am sure that I vote by post”. • “My nephew helped me when I voted the last time”. A member of staff responsible for ensuring that the details of residents living in the home were included on the electoral roll said, “The Borough send me a list of registered voters and I then update the record and I ask each individual if they want to vote or abstain, or have a postal vote. I do that about every six months. If I have any questions I can talk to someone at the Borough. I also keep them informed of our deaths”. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 25 The home’s bedrooms accommodation was well maintained, furnished and equipped for service users safety and specific needs. EVIDENCE: All residents spoken to expressed contentment with the condition of the bedroom accommodation including the furniture and equipment in them. Comments from residents about these matters included: • • • • “It is alright, I could do with more space but then I would only fill it with more clutter. It is warm as you can see I am growing cactus plants. The lighting is fine”. “It is very good and spacious, lovely for one person. It is lovely and warm”. “I like it, I have no complaints about anything. The artificial lighting is fine as there is also a light over the bed”. “The room has got everything, the private toilet, comfy bed, central heating and they keep it clean”. DS0000011413.V274313.R01.S.doc Version 5.1 Page 17 Ashley Lodge Residential and Nursing Home Bedrooms viewed varied in size and configuration but were furnished and equipped as expected by Standard 24 of the National Minimum Standards for care Homes for Older People. The furnishings of the rooms and décor were in good repair. All bedrooms were; fitted with carpets; doors were fitted with suitable locks; naturally ventilated and heated by radiators that were covered with guards to prevent residents from the risk of burns. All shared bedrooms viewed were provided with screening to provide privacy. The nurse call system was tested in two rooms. It was working and staff responded very quickly when it was activated. The temperature of the hot water stored and being “delivered” in the home was tested regularly by persons working in the home with responsibility for health and safety matters. In addition the home’s head of care said that nursing and care staff always tested and recorded the temperature of the hot water to ensure that it was safe before helping residents with bathing. Records indicated that hot water was being stored at around 80°C to eliminate the danger of Legionella bacteria and delivered at around 43°C to eliminate the risk of scalding (see also Standard 38 at page 22). Hot water outlets were randomly tested during this inspection visit and the temperature of the water was “comfortable”. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home’s commitment to and staff training and development was good, ensuring that staff had opportunities to acquire relevant skills and achieve a necessary level of competence. EVIDENCE: All new care staff completed an induction-training programme that satisfied the requirements of “Skills for Care”. (The sector training organisation that replaced the “Training Organisation for Personal Social Services” [TOPSS] in April 2005). Staff training needs were identified through appraisals and individual supervision sessions and staff spoken to indicated that they appreciated the opportunity to increase their knowledge and skills. The home had implemented a programme of monthly training sessions “Back to Basics” that included the following topics. • Care Planning • Abuse • How we treat our clients • Catheter care • Oral hygiene • Care of the dying (physical) • Basic Observations • Care of the dying (psychological) • Infection control • Communication Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 19 The training methodology included meeting in small groups, study sessions, one to one and distance learning. All staff spoken to had attended training courses relevant to the care the home provided. • “I have NVQ 2 – we do other stuff as well much more that the usual health and safety training - I have done catheter care, care of the dying that was about their mental state and will be doing more about the physical care of the dying soon – I have done care planning – and diabetes - we discuss training at our appraisals and I said that I wanted to know more about strokes and that is coming up”. Enthusiastic views were also expressed by staff about working in the home. • “On the whole I love it, we all have our ups and downs, but it is a very happy place and the staff all get on”. Staff records included details of training courses that the individual concerned had attended. Details of the whole staff team had been collated and the home’s staff training needs could be identified readily. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 38 The home’s manager had the experience and skills necessary to run the home effectively. Systems for managing health and safety in the home were excellent ensuring that the welfare of staff and residents was promoted. EVIDENCE: The registered manager was a registered nurse and had been responsible for the day-to-day functioning of home for almost 4 years. She had obtained the Registered Managers Award During the last 12 months she had kept up to date with developments, maintaining and improving her knowledge and skills by attending seminars/workshops arranged and had because of her knowledge and experience been acting as mentor for colleagues at other homes working for the company that also owned Ashley Lodge. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 21 Staff and residents spoken to indicated that the manager was efficient, friendly and approachable and that they had confidence in her and clinical knowledge and skills. There was evidence from both discussions and records that all staff working in the home had received regular training in health and safety subjects that were relevant to their role in the home. These included first aid, fire safety, food hygiene, moving and handling, infection control and control of substances hazardous to health. The home had a health and safety committee that met regularly and was “made up” of representative from the staff groups/departments in the home. The person responsible for health and safety matters in the home (health and safety officer) kept comprehensive and clear records that indicated that risk assessments for safe working practices were completed and that all systems and equipment in the home were tested and serviced at intervals and with the frequencies either required according to relevant regulations or good practice. These included: • Fire safety equipment • Electrical wiring • Gas appliances and central heating • Portable electrical appliances • Hoists and slings • Lifts • Hot water systems –(tested for temperature and the presence of Legionella). One senior member of the home’s staff commented about the home’s health and safety officer and said that he ensured that “staff feel safe working here”. Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X X X X X 3 3 X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 4 Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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 Ashley Lodge Residential and Nursing Home DS0000011413.V274313.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!