CARE HOMES FOR OLDER PEOPLE
Elizabeth Lodge 29 Beech Grove Alverstoke Gosport Hampshire PO12 2EJ Lead Inspector
Annie Billings Unannounced Inspection 8th August 2006 11:30 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 Elizabeth Lodge DS0000065980.V303427.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. Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Elizabeth Lodge Address 29 Beech Grove Alverstoke Gosport Hampshire PO12 2EJ 023 9258 0802 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) Mr David Mitchell Mrs Karen Ritchie Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 29th December 2005 Brief Description of the Service: Elizabeth Lodge is situated in Alverstoke, near Gosport, in a quiet residential cul-de-sac. The building is in keeping with surrounding houses in the vicinity and close to local amenities. The home provides care for up to 18 older persons, some of who may have dementia. Accommodation is provided over three floors, in single, en-suite bedrooms. There is one lounge/dining room, which includes a conservatory, and a smaller lounge/dining room, which is used for residents who have a higher level of need. The home is well maintained and adequately furnished. To the rear of the property is a large enclosed, secure garden, and ample parking facilities are available at the front of the premises. The current fees advised within the pre-inspection questionnaire are between £55 and £72 per day, excluding hairdressing and chiropody. Toiletries, newspapers, external activities and community transport are charged at cost. Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection on the 8th August 2006 took place over four hours, with an additional visit for a further three hours on the 9th August to hold discussions with the residents and the provider. An opportunity was taken to look around parts of the home, view some records and talk to five staff and six service users. All of the core standards were assessed during these visits, and three previous issues identified at the last inspection were followed up. Additional information was supplied within a pre-inspection questionnaire, and comment cards received from three service users’ relatives and one community health care professional. What the service does well:
Comments received from relatives and one community health care professional were positive about the service, confirming they are welcomed into the home, that there are always sufficient numbers of staff on duty, they are kept informed by the home and are satisfied with the overall care provided. One relative said, “Elizabeth Lodge is excellent. I can’t fault any aspect of the care given and would recommend this home to other people …”. Comments from residents were equally positive, confirming that they feel safe and secure, that staff are friendly and respect privacy and dignity, routines in the home are flexible, that the home is kept clean and clothes well laundered. Others said there were suitable activities, they liked the food and were happy to see the improvements being made to the home by the new owner. The home is friendly and welcoming, providing residents with a homely, comfortable environment to live in. A satisfactory complaints procedure has been established, which some residents and relatives confirmed they are aware of, and feel able to use. Residents are supported by well-trained staff who have been thoroughly checked prior to employment to ensure their suitability. The home is well managed and run in the best interests of residents. Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
A number of issues were identified during the visit that required urgent attention. One bedroom has been without hot water since new thermostatic valves were fitted, and the resident concerned described this as “annoying”. This has led to unsafe practice, with care staff carrying jugs of hot water from the floor below. This was discussed with the provider, who is already looking at alternative ways of heating water to this bedroom, possibly with an individual supply, and has agreed his intention to undertake this work as a matter of urgency. Meanwhile, the manager put a risk assessment in place immediately, to ensure that action is taken to ensure the safety of staff. A number of first and second floor windows were not fitted with restrictors, which could put residents at risk. Both the manager and provider had an awareness of this, and intend to have these fitted, although the manager needs to consult with the fire safety officer in respect of the first floor landing window. Unlocked cupboards containing the hot water tank and uncovered hot water pipes were identified, which could be a potential risk to residents with
Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 7 dementia. A risk assessment was undertaken immediately, and the provider gave assurances that action would be taken promptly to reduce any risk to the residents. Commode bowls were found soaking in disinfectant in two of the en-suite facilities, which could be harmful to residents. These were removed immediately, and alternative practices put into place. The provider has not developed a development plan for the home, or a system of internal audit, to ensure the service continues to improve. Arrangements have already been made for someone to undertake monthly visits to the home, but these have yet to be implemented. The provider visits and meets with the manager on a weekly basis, but there is no system of formal supervision, as visits are not documented. Immediate action has been taken or is planned to address all of these issues, which will be assessed on the next visit. 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. Elizabeth Lodge DS0000065980.V303427.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 Elizabeth Lodge DS0000065980.V303427.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 at least once during a 12 month period. 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 the service. People’s needs are fully assessed prior to admission so the prospective residents and the home can be sure their needs can be met. An intermediate care service is not offered by the home. EVIDENCE: Pre-admission assessments were available in three residents’ files sampled, which had been undertaken prior to the person moving into the home. Where possible, the prospective resident or representative had been asked to sign the document, to demonstrate their involvement in the process. The manager said they then confirmed in writing that the home could meet the person’s needs. Copies of care management assessments were also available, where residents are funded through Social Services. Where a risk had been identified, individual risk assessments had been undertaken, and measures put in place to minimise the risk. A falls register is
Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 10 maintained and the manager advised that if a resident fall three times, they are referred to a local falls co-ordinator for assessment and possible issue of free hip protectors. One resident, accommodated on the second floor had fallen recently. The hoist is not available on this floor, and the manager has agreed to put a moving and handling risk assessment in place to ensure that staff follow appropriate moving and handling techniques. The manager confirmed that the situation is being monitored, to identify any future need to move the resident to the ground floor. The home does not provide an intermediate care service. Elizabeth Lodge DS0000065980.V303427.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 at least once during a 12 month period. 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 the service. Systems are in place to ensure that personal care, health and medication are well managed. Residents are treated with respect, and their right to privacy promoted. EVIDENCE: Care plans and other documentation were sampled within the three most recently admitted residents’ files. The care plans seen provide staff with specific guidance on how to meet peoples’ needs, how to promote independence and choice, and their preferences in relation to daily routines, and demonstrate where possible the involvement of the service user or their representative in this process. Staff confirmed these are used as working tools, and there are good systems of communication in place, to ensure they are aware of changes in care. Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 12 Evidence of monthly reviews were available, as well as day and night evaluations and a three monthly dependency assessment tool, which ensure that care plans are adapted to meet changing needs. From discussions with staff, they have a good understanding of residents’ needs, although the manager has been encouraged to expand the recording of specific communication needs, behaviour patterns and activities, to further demonstrate that needs are being met. Records of health support are good, and identify prompt referral to health care professionals when necessary. This was confirmed by comments made by a health care professional. The manager also advised of recent referral to a dietician or nutritionist where a need arose. Recording systems are introduced to ensure that where a specific health care need is identified, i.e. fluid charts to encourage fluid intake, these are appropriately addressed. The home operates a monitored dosage system for the administration of medication, supplied by the local pharmacist, although the manager advised they were planning a change of supplier. The records seen in relation to this are well maintained. Residents confirmed they receive their medication at regular times, and procedures are in place to monitor stock levels of medication weekly. Following a recent pharmacy audit it was discovered that ½ tablet of temazepam was missing. This was reported to the commission, and all staff were retrained in the safe handling of medication, as a result. The missing ½ tablet was discovered during the inspection. The manager advised that the new pharmacist will be offering annual update training to staff, as well as upgrading current storage facilities, in line with best practice guidelines. Stocks of insulin were stored appropriately, and resident’s consent for assistance and training records were in place. Residents spoken with confirmed they are treated with respect at all times, and that any care is undertaken in the privacy of their own room. A local community nurse also commented that the home communicates well, that privacy is respected and is satisfied with overall care. A relative commented, “Elizabeth Lodge is excellent. I can’t fault any aspect of the care given and would recommend this home to other people …”. Elizabeth Lodge DS0000065980.V303427.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 at least once during a 12 month period. 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 the service. Routines are flexible, allowing residents to exercise control over their lives. Family contact is encouraged, and activities and diet are well managed, offering variety, choice and a nutritional diet. EVIDENCE: Discussions with residents confirmed they are happy in the home and that routines are flexible, and based around their own preferences. Staff were able to advise of how choice is promoted to all residents, including those with dementia, and this was supported by guidelines within the care plans seen. One resident described how their particular religious needs were met with church visitors coming to the home fortnightly, and singers once a month. Other residents said they felt that activities were appropriate, and some joined in. External entertainers come to the home on a regular basis, although care staff undertake daily activities with the residents. The range of activities includes arts and crafts, music for health, quizzes, story telling, local shows and occasional trips out. The manager has been encouraged to consider staff training as an area of future improvement, to ensure that activities are appropriate to all of the residents, and based around their interests.
Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 14 Both residents and relatives confirmed that visitors are welcomed into the home. Menus sampled offer variety and choice, and have been developed following consultation seen within quality assurance records, and on residents’ preferences. Nutritional assessments are basic, although the manager advised that residents are referred to a dietician or nutritionist if a need for professional advice arises. Observation at lunchtime confirmed that residents could choose where to eat, the availability of further variation to the menu, appropriate assistance from staff and the supply of specialist utensils to promote independence. Good practice was demonstrated by staff sitting and eating with less able residents, to encourage healthy eating practice. Residents spoken with confirmed they generally liked the food, and advised of a recent barbecue held in the garden. One of the residents is a vegetarian, and the manager advised that the resident is taken shopping, to allow them to choose the foods they like to eat, as they cannot communicate their wishes. This is seen as excellent practice to promote diversity, choice and independence. Elizabeth Lodge DS0000065980.V303427.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 inspected at least once during a 12 month period. 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 the service. A complaints procedure has been developed that residents and relatives are aware of. Staff have an awareness of abuse and the appropriate reporting procedures, which ensures that residents are protected. EVIDENCE: The home has developed a complaints policy and procedure, which all of those residents and relatives who commented said they were aware of. Minor alterations have been requested to ensure that residents have correct information, as this refers to the local authority inspection unit, which no longer exists. Relatives confirmed their awareness of the policy, and residents spoken with said they felt able to talk to staff and the manager if they were unhappy, and felt confident that something would be done. No complaints have been received since the last inspection. All staff spoken with had an awareness of the reporting procedures in the event of a suspicion of abuse, although not all had received formal training in abuse awareness. The manager has an awareness of this, and intends to provide this in the future. Elizabeth Lodge DS0000065980.V303427.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements are being made to the home to ensure it is well maintained, although shortfalls identified must be dealt with promptly, to ensure that residents and staff are safe. The home is kept clean and hygienic. EVIDENCE: A partial tour of the home confirmed that communal areas are homely and comfortably furnished. There is one lounge/dining room, which includes a conservatory, and a smaller lounge/dining room, which is close to the central area of staff activity, and is used for residents who have a higher level of need. The large lounge currently has only one staff call bell, and in the event of an emergency this could cause difficulties and delays if residents have mobility problems. This was discussed with the manager, who advised that this had been raised during a residents meeting, and had been brought to the attention
Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 17 of the provider for action, although an additional hand bell has since been provided. A new radiator has been fitted, and is waiting to be covered. As the heating system is not currently being used, this did not pose any risk to residents. Seven bedrooms sampled were appropriately furnished, and had been personalised by the residents. Commode bowls were seen soaking in disinfectant in two of the en-suite bathrooms. This practice presents a risk to people with dementia, and the manager took prompt action to have these removed, and to implement safe systems of cleaning. Since taking over the home in January, the provider has been addressing shortfalls inherited within the premises, in order of priority. Thermostatic valves have been fitted to all bedroom and bathroom taps, to ensure that water is delivered at a safe temperature. This has caused a problem in one bedroom, as hot water to the basin is no longer available. The resident said they were still able to have a wash, but there had been no hot water all week, which they found “annoying”. The manager advised that care staff were carrying jugs of hot water to the room. This is not safe practice, and the manager put a risk assessment in place immediately, to ensure that measures are taken to reduce the level of risk. A number of windows on the first and second floors have not been fitted with window restrictors, although the manager and provider said they are aware of the need. These present a possible risk to residents, and the manager put risk assessments in place immediately. These issues were later discussed with the provider, who advised they are taking appropriate action as quickly as possible, although a window restrictor could not be fitted to one window, until they had consulted with the fire safety officer. The manager agreed to do this the following day, and to keep the commission informed of the action recommended. The manager and provider have a good awareness of the shortfalls that need to be addressed, and action was already being taken in order of priority, therefore no requirements were made. The provider also advised of further improvements planned for the home, including the purchase of new furniture to replace miss matching bedroom furniture in due course. Storage cupboards housing the immersion and hot water tank were found unlocked. These contain uncovered hot water pipes, which could represent a risk to residents. The manager put a risk assessment in place immediately, and the provider agreed to ensure these areas are made safe. Since the last inspection the rolling programme of decoration has continued, to include WC’s, laundry, office and one bathroom, although the bin lid was missing and the bath panel is showing signs of wear and need to be replaced. Following risk assessments undertaken as a result of the last inspection, gates have been removed from both staircases, to ensure residents can move freely around the home. A new shower room has been installed to replace a second
Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 18 bathroom, following consultation with the residents, as this did not meet their needs. All areas of the home seen were clean and hygienic. Residents confirmed that the home is kept clean, and their clothes well laundered. The external grounds were safe, secure and well maintained. Shaded areas had been provided, for those wishing to sit outside. Elizabeth Lodge DS0000065980.V303427.R01.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 at least once during a 12 month period. 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 the service. Residents are supported by well-trained staff, in sufficient numbers to ensure that residents’ needs are met. Residents are protected by the home’s recruitment process. EVIDENCE: Comments received from three relatives and one community nurse confirm that in their opinion there are sufficient staff on duty. Observation during the visit and sampling of staff rotas confirmed this, with staff observed giving appropriate assistance when needed. Residents said that “staff are lovely”, “ very friendly – they make me feel safe and secure”, and “kind and respectful”. The manager said there had not been a need to employ agency staff for some while. Of the fifteen care staff, eight have already achieved a National Vocational Qualification Level 2 or above, with others waiting to start the course. Three staff files were viewed, which confirmed that appropriate checks, including a criminal records bureau check, are undertaken prior to employment, to ensure they are suitable to work in the home. Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 20 Since the last inspection, the provider has introduced a new induction and training programme for staff, to ensure they are trained to a high standard. Workbooks were sampled, and a reminder given to ensure that all competency assessments are signed and dated. The deputy manager responsible for assessments advised that medication competency assessments are also undertaken, although these are currently not recorded. It was agreed that these would be added to the workbooks in future. Records seen confirm that update training is provided regularly, and that training in core skills are up to date. Formal training in abuse awareness is currently being planned. Discussions with staff confirmed they feel competent in their role, that training is plentiful and their development encouraged. They all confirmed they are well supported by the manager, that they are given clear guidance and direction, and that they are encouraged to contribute to the running of the home. One said there is, “a good team spirit, they work well together”. All confirmed they do not feel overworked, and when needed, additional staff are made available, although one said they would prefer to have more 1:1 time with the residents. Elizabeth Lodge DS0000065980.V303427.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well managed, and run in the residents’ best interests. Systems are in place to ensure that residents’ financial interests are safeguarded, and that the environment is maintained in a safe way, but prompt action must be taken to address the issues identified to ensure that staff and residents remain safe. EVIDENCE: The registered manager has worked in the care sector for over 22 years, has recently achieved an NVQ4 in care and the Registered Managers Award, and regularly updates her own training to ensure she remains aware of best practice guidelines. Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 22 A quality assurance system has been developed, which includes questionnaires sent to families, and reviewing of care plans every six months with family involvement, if appropriate. Residents’ meetings are held six monthly, to which relatives are invited to contribute, and feedback is given at the following meeting on action taken to address any issues raised. The manager confirmed that the new provider is very involved in the running of the home, is very supportive and takes prompt action to address any issues identified. They advised that they meet on a weekly basis, although no formal supervision is undertaken. There is currently no system of self-audit or monitoring of the service. The manager said that arrangements had been made for Regulation 26 visits, but these have yet to be done. These matters were discussed with the provider, who agreed to put these into place. The home looks after personal allowances on behalf of some residents. Records were well maintained and balances checked against the records. Receipts are kept for items which are bought. As a result of the last inspection, locks have now been placed on all cupboards containing cleaning products that may be hazardous to residents. Following risk assessments undertaken, stair gates have been removed from both staircases, to allow residents to move around the home freely. The manager advised these had been put in place to safeguard a resident no longer living in the home. Records seen confirm that all equipment in the home is well maintained and serviced on a regular basis. Fire training records were up to date, and following a recent visit from the fire safety officer, action was being taken to replace signage where advised. The maintenance book was checked, and records confirmed that appropriate action had been taken to address issues identified. Shortfalls identified within the environment, and unsafe care practices observed were addressed immediately by the manager, and appropriate risk assessments put in place, or changes made in care practice during the inspection. The manager and provider have a good awareness of the shortfalls that need to be addressed, and action was already being taken in order of priority, therefore no requirements were made. Elizabeth Lodge DS0000065980.V303427.R01.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 X X 3 X X N/A 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 2 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 X X 2 Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 25 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 Elizabeth Lodge DS0000065980.V303427.R01.S.doc Version 5.2 Page 26 - 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!
