Inspection on 04/08/09 for Friars Lodge

This inspection was carried out on 4th August 2009.

CQC found this care home to be providing an Adequate service.

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.

Other inspections for this house

Friars Lodge 22/09/08

Friars Lodge 28/09/07

Friars Lodge 15/11/06

Friars Lodge 01/12/05

Friars Lodge 09/08/05

Friars Lodge 09/03/05

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Friars Lodge 18 Priory Road Dunstable Bedfordshire LU5 4HR Lead Inspector Mrs Louise Trainor Key Unannounced Inspection 4th August 2009 08:00 DS0000062259.V377004.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Friars Lodge Address 18 Priory Road Dunstable Bedfordshire LU5 4HR 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) 01582 668494 F/P 01582 668494 friarslodge@live.co.uk Friars Lodge Ltd Manager post vacant Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (20) Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide accommodation for twenty people over the age of 65, four of whom may be accommodated in two rooms for double occupancy where it can be shown that the decision to share was a positive choice. 22nd September 2008 Date of last inspection Brief Description of the Service: Friars Lodge is a private residential care home and is registered to provide care for twenty older people. The home is located in a pleasant residential area of Dunstable and is within close proximity to the Priory and the towns amenities. The bedrooms are on three floors that are accessible by a staircase and a newly installed shaft lift. Toilets and adapted bathing facilities are located for convenient access throughout the home. A large lounge with dinning area and a small visitors/quiet lounge are situated on the ground floor. The lounge area overlooks an established and well-maintained garden to the rear of the home. Parking is available for a few vehicles at the front of the building. However there is also some road parking close to the home. Fees for the home are between £457.06 and £550 a week depending on the room provided. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out in accordance with the Care Quality Commissions (CQC) policy and methodologies, which requires review of the key standards for the provision of a care home for older people that takes account of residents views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgments made within the main body of the report include information from this visit. This was the first Key Inspection for this year for this service. Regulatory Inspectors Mrs Louise Trainor carried it out on the 4th of August 2009 between the hours of 08:O0 and 15:00 hours. The home Area Manager Mrs Kirsty Janes was present at the home for most of the day, working through an induction programme with the new manager June Henderson, who had come into post on that day. The Deputy manager Lucy Aristido, who has been acting as manager since the previous manager left in early July, was present throughout this visit and assisted with any required information. Verbal feedback was given periodically throughout the inspection and at the end of the visit. During the inspection the care of two people, including the most recent admission to the home, were case tracked. This involved reading their records and comparing what was documented to the care that was being provided. Documentation relating to: staff recruitment, training and supervision and medication administration, complaints, quality assurance and health and safety in the home were also examined. We also had a tour of the premises and spent some time in the communal areas of the home, talking to the residents and visitors, and observing the care practices and interventions that were carried out during this seven hour inspection hour inspection. We would like to thank everyone involved for their support and assistance during this visit to the home. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 6 What the service does well: The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of needs has been carried out so that prospective residents and their representatives can be sure that their needs will be met. This home has a complaints policy, which is easily accessible to residents and visitors to the home. It details expected timescales for responses, and guidance for any complainant that remains dissatisfied with ‘in house’ investigatory outcomes. Safeguarding is addressed with staff in this home through the induction process, and is also included in the mandatory training schedule. The training matrix indicated that all the staff have attended this training. The home provides a clean, comfortable and safe home, which is well maintained, for the people who live here. Observations of staff and residents interactions indicated that there is a familial, relaxed and friendly atmosphere in this home, and the staff were confident and competent in their roles. The service has a strong commitment to ensuring residents maintain personal relationships that are important to them. Suitable and meaningful activities are encouraged, and individual’s are assisted and supported to make personal choices. Recruitment procedures are fully adhered to so that residents are protected. The service ensures that all staff within its organization receives relevant training that is targeted and focused on improving outcomes for residents. We addressed the supervision records for staff with the deputy manager. This is taking place on a regular basis, and all staff have received at least one supervision session since May/June 2009. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Friars Lodge DS0000062259.V377004.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 Friars Lodge DS0000062259.V377004.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 People using the service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of needs has been carried out so that prospective residents and their representatives can be sure that their needs will be fully met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a combined Service User Guide and a Statement of Purpose in place for this home. This document is held electronically and reviewed at regular intervals, then issued to people as they enquire about the home. The document we were shown had been reviewed within the last month. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 10 Since the last inspection this document had been amended and now contains the full range of fees relating to the service. There are clear details of what is included in the fees, and what is provided at an additional cost, such as hairdressing and chiropody. The individual fees for each resident are also clearly identified within their contract of terms and conditions. We looked at the file of the two residents; one of which had been admitted since our last inspection, in September 2008. The pre admission assessments are being carried out in advance of admissions, and contain sufficient detail to ensure that the staff are able to meet their needs. Contracts for three of the residents were checked and were all signed and dated appropriately. This home does not provide intermediate care Friars Lodge DS0000062259.V377004.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People using the service experience adequate quality outcomes in this area. The home understands the need to comply with medication policies; however auditing processes and stock control are ineffective at present. Person centred care planning is in place, however some would benefit from more detail, and regular reviews should be maintained so that changing needs are met efficiently. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we looked at the files of two residents in detail. Files were tidy and generally well organised. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 12 Care plans were well written, and were generally in sufficient detail to ensure that staff could deliver care with continuity. Since our last visit to the home, new care plan documentation has been introduced. It clearly identifies one ‘need’ per page, with a specific prescription of care for staff to follow, ensuring that continuity is maintained. For each ‘need’ there is a corresponding evaluation sheet in place. These were generally being reviewed and updated as and when individual’s needs changed, however this has slipped since the departure of the manager. The area manager told us that this new documentation is being introduced to all the company’s homes, and she hopes it will encourage staff of all levels to make changes and become more involved with the care planning process, using them as working documents, as they do the daily log sheets. Both of the files that we looked at contained numerous care plans ranging from personal care to social activities and behaviour. These were generated from information in the pre admission assessments. For one resident the care plan identified that due to two previous Cerebral Vascular Accidents (CVAs), there is both cognitive impairment and some physical weaknesses, particularly in this persons’ hands, and for this reason adaptive cutlery with chunky handles should be used, and assistance offered at meal times. It identified that although this person mobilises independently, staff should be aware that he walks with a shuffle. There was information about behavioural changes that could be expected and details about how to recognise triggers for these behavioural changes, and how they should be managed. Medications were clearly listed with a warning that certain drinks should not be consumed due to potential contraindications. The care plans were generally written in detail and in a person centred way, so that staff knew the level of assistance required to meet this persons needs in a way that they prefer. However the file that we looked at for a more recently admitted resident, had omitted to identify a personal condition, which the resident personally told us about. This was a condition that all staff, who assists this resident with personal care, should be aware of to ensure that her care and comfort is managed appropriately. We could see from the care plans that generally they are regularly reviewed, however the deputy manager told us that since the manager had left, this had slipped slightly and most plans were either due or overdue for review. With the new home manager in post, we are confident this will be addressed as a priority. Residents in this home were relaxed, happy and well presented. Observations of care, identified people being treated with respect, and addressed in a way that was their preference. Call buzzers were being answered by staff in a timely fashion. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 13 During this inspection we examined the Medication Administration Record (MAR) sheets for all the residents who live here. These were tidy and well presented however there were several omissions of signatures and codes, and the reverse of the MAR sheets were not always being completed appropriately. Most of the medication that was dispensed in blister packs, and the medication prescribed on a regular basis and dispensed monthly in boxes reconciled correctly. However the ‘as required’ medications such as paracetamol, were not being clearly recorded when they were carried forward from month to month, therefore it was not possible to reconcile them. We also noted that one residents’ analgesia, which she had been receiving four times a day, had run out the previous evening, and although it was due to be delivered, two doses had been missed. We did speak to the resident in question, and although she does generally suffer with a lot of pain, she told us she was not in pain at the moment. Another resident was prescribed an anti depressant once a day. The code ‘R’ had been recorded when the morning medication round done, with a note overleaf that explained the resident was sleeping. There was nothing to suggest this tablet was offered again during that day. We discussed these matters with the area manager, who agreed a review of the medication auditing process was needed immediately. There is presently one resident in the home prescribed Controlled Drugs. These were all stored and recorded appropriately, and reconciled correctly with stocks remaining. The ‘drug fridge’ and room temperatures were being recorded daily to ensure correct storage was being followed for all medications. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. The service has a strong commitment to ensuring residents maintain personal relationships that are important to them. Suitable and meaningful activities are encouraged, and individual’s are assisted and supported to make personal choices. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Generally in this home, activities are arranged and delivered by the care staff. One of the senior carers takes the lead on this. External entertainers also visit from time to time. Daily activities are varied and include a visiting library, visiting clothes shows, gardening, weather permitting, trips into the local town and tea rooms, board games, and personal pampering of hair and nails. Although everyone is Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 15 encouraged to participate, it is accepted that not everyone wishes to do so all the time. Although there were no group activities going on during this visit, there were several residents reading the newspaper, one doing crossword puzzles and one doing a jig saw puzzle with a member of staff. Staff were integrating well with residents, stopping to chat with residents as they passed through the lounge area going about their daily tasks. Stimulation for the residents that were being nursed in bed was also addressed. For example, for one resident, who had a love of flowers, her bed had been turned round to face out onto the garden, as that’s how she preferred it. From her bed she could see the flowers, birds etc, and anything else that maybe going on in the garden. We spoke to her and she was very happy with this arrangement. Families and friends are welcome in this home at any time, and residents are encouraged to maintain these relationships. One relative that we spoke to was a regular visitor to the home to visit her loved one, and she told us that she usually stays and has a meal in the home at least once each week. There is a four week rolling menu plan in place for this home, which offers a wide range of healthy nutritious meals. On the day of this inspection there was a choice of pork in sauce or steak in gravy, both served with a choice of vegetables, freshly picked from a local sister home. There was also a choice deserts, which on this particular day was pear crumble and ice cream or fruit salad for There was a supper menu available which offered lighter bites such as jacket potatoes, egg and chips and soups, and individual portions of a variety of main course dishes were frozen for use at a later date. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home has a complaints policy, which is easily accessible to residents and visitors to the home. It details expected timescales for responses, and guidance for any complainant that remains dissatisfied with investigatory outcomes. We viewed the complaints and compliment files. The home had not received any complaints since the previous inspection. There were however numerous cards of thanks. One read. “Just to thank you for the wonderful care that our mother received during her two years at Friars Lodge. It was like becoming part of a large family.” Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 17 Safeguarding is addressed with staff in this home through the induction process, and is also included in the mandatory training schedule. The training matrix indicated that all the staff have attended this training. We are aware from experience that this service liaises closely with the CQC and the local safeguarding team when appropriate. The training matrix also indicated to us that the Mental Capacity Act (MCA) was being address with staff through training. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People using the service experience good quality outcomes in this area. The home provides a clean, comfortable and safe home, which is well maintained, for the people who live here. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home was clean and free from offensive odours, and generally well maintained. This home has sixteen single bedrooms, and two double rooms with en suit facilities. One of the double rooms is occupied by a married couple, who have Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 19 recently celebrated their 70th wedding anniversary, and the other has only been used for single occupancy over the past year. Bedrooms are decorated individually to meet with each person’s preferences. The residents can identify their rooms both by numbers and names which are displayed on the doors. The rooms are furnished with personal assets, ornaments and photographs that reflect the lifestyle and personal history of each resident. Communal areas were spacious, homely and comfortable. The kitchen was clean, with well stocked fridges and freezers. Generally food was being dated on opening; however we did see a jar of fish paste which had not been dated, despite a product note “eat within 3 days of opening”. This home has large gardens laid mainly to lawn at the rear. These are surrounded by high shrubs giving privacy to anyone wishing to use them. The gardens are secure and can be easily accessed by residents, via gentle sloping ramps, allowing them the freedom to wander and enjoy the fresh air, weather permitting. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. Recruitment procedures are fully adhered to so that residents are protected. The service ensures that all staff within its organization receives relevant training that is targeted and focused on improving outcomes for residents. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The usual staffing levels during the day in this home are three care staff and the manager, supported by cleaning, maintenance and kitchen staff. During the night there is two care staff on duty. We examined the personal files of four staff. All had Criminal Record Bureau checks and POVA first checks in place. All had fully completed application forms that detailed employment history and personal qualifications, and two appropriate references. However for one of the senior carers, whose file we looked at, we could only locate an application form for a cleaner’s position, Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 21 dated 2006. We could not locate any evidence to identify when her role had changed. All three had either completed, or were presently working through an induction programme. Home Office documentation was in place where appropriate. Contracts of terms and conditions were in place, correctly dated and signed. This homes’ sister home that is situated locally has its’ own training rooms, and the area manager is an NVQ assessor. Training records indicated that over 50 of staff have achieved NVQ certificates in care at varying levels, and a wide range of non mandatory training course are also available to staff, including Dementia, Challenging Behaviour and Death and Bereavement. Most of the staff have attended all mandatory training and refresher courses as required, and where they are due, courses have been booked. Observations of staff and residents interactions indicated that there is a familial, relaxed and friendly atmosphere in this home, and generally the staff were confident and competent in their roles. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 People using the service experience adequate quality outcomes in this area. Checks show that records are generally up to date, however some gaps were found in the records and auditing processes, which may increase risks for people who live in this home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home is very family orientated, with various family members involved in different roles. However there has not been a registered manager in this home for approximately two years. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 23 The most recent manager for this home, who had declined to register, left her position in early July 2009, and a new manager has been appointed. The day of this inspection was the new manager’s first day of induction. She is experienced in social care, however not specifically with older people. She is keen to commence her Registered Managers Award (RMA) and increase her knowledge and skills in this area. She is supported by a very experienced and capable deputy manager. This home provides care with a person centred approach, with the best interests of the residents being a central focus. The care is delivered by a committed team of staff, some of which have worked in the home for several years. Files are tidy and well maintained and stored securely. . One file that we looked at contained a care plan relating to personal finances. We were a little concerned that this had been signed by a family member and not the resident themselves, despite them having capacity to do so. Residents have the option of a key for their bedroom if they so wish. We addressed the supervision records for staff with the deputy manager. This is taking place on a regular basis, and all staff have received at least one supervision session since May/June 2009. During this inspection we examined the health and safety files. This included numerous health and safety risk assessments including one for fire, however this had been completed by the previous manager before she left and it was not signed or dated. Records identified that health and safety checks including water temperatures, fire call bells, and freezer and food temperatures are being recorded appropriately, and any anomalies identified are addressed in a timely fashion. We did however note that fridge produce was not always dated when opened, for example there was a jar of shrimp paste that had been opened and not dated. The product label stated ‘use within three days of opening’. This home addresses quality assurance on an annual basis via questionnaires to residents, relatives and visiting health professionals. This year’s annual report is still in progress. We look forward to seeing the completed document. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 24 Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 25 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 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 X 2 3 3 2 Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP7 Regulation 15 (2) (b) Requirement People who use this service must have care plans that are reviewed promptly to address changing needs efficiently. Medication for people, who live in this home, must be audited regularly to ensure that stock control is managed appropriately. People who use this service should have access to a copy of the annual quality review report for the home. A copy of this report must be submitted to CQC. People who live in this home must be protected by a full fire risk assessment which is appropriately dated and endorsed. Timescale for action 30/10/09 2. OP9 13(2) 31/08/09 3. OP33 24(2) 30/09/09 4. OP38 17(2) 31/08/09 Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The manager should consider more regular auditing of medication stocks, with a particular focus on those not provided in blister packs. Friars Lodge DS0000062259.V377004.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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