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Inspection on 22/05/09 for Sovereign Lodge

Also see our care home review for Sovereign Lodge for more information

This inspection was carried out on 22nd May 2009.

CQC found this care home to be providing an Good 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.

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

What has improved since the last inspection?

What the care home could do better:

The manager and provider have their own action plan for the further development of this service.

Key inspection report CARE HOMES FOR OLDER PEOPLE Sovereign Lodge Newbiggin Lane Westerhope Newcastle Upon Tyne Tyne & Wear NE5 1NA Lead Inspector Mary Blake Key Unannounced Inspection 09:30 22nd May 2009 DS0000000456.V376001.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. Sovereign Lodge DS0000000456.V376001.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 Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sovereign Lodge Address Newbiggin Lane Westerhope Newcastle Upon Tyne Tyne & Wear NE5 1NA 0191 2714029 0191 271 4026 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) Mrs Jennifer Houghton Manager post vacant Care Home 48 Category(ies) of Dementia (48), Old age, not falling within any registration, with number other category (48) of places Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: To services users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 48 2. Dementia Code DE - maximum number of places 48 The maximum number of service users who can be accommodated is: 48 5th November 2008 Date of last inspection Brief Description of the Service: Sovereign Lodge is a modern, purpose built residential home. It has 46 single bedrooms, all bar two of which have en-suite facilities. Most accommodation is on the ground floor. The home has 5 lounges and 2 dining rooms. There is a pleasant garden with seating. It is situated in Westerhope, a suburb of Newcastle upon Tyne, and is quite close to local shops. It is on a bus route. The current fees are £355 to £425 per week. The service user guide and inspection report were available at the entrance. Sovereign Lodge DS0000000456.V376001.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 2 star. This means that the people who use this service experience good quality outcomes. An unannounced visit was made on the 22nd May 2009. The manager and company representative were present throughout the inspection. Before the visit: We looked at: • Information we have received since previous random inspection in November 2008. • How the service dealt with any complaints and concerns. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff and other professionals. • The Annual Quality Assurance Assessment (AQAA), which is a selfassessment document, was sent to the home for their completion. During the visit we: • Talked with people who use the service, relatives, staff, the manager and company representative. • Looked at information about the people who use the service and how well their needs are met, • Looked at other records which must be kept, • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for, • Looked around parts of the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit We told the manager and company representative what we found. What the service does well: Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 6 Staff were kind and considerate when helping people who use the service. People who use the service and relatives explained the admission process; this usually includes a visit from the manager. This helps new residents identify their own needs and enables staff to meet their needs during their stay. The service gives good support to enable individuals to make decisions and participate in the running of the home. People who use the service said, and it was seen, that staff were kind, considerate and supportive. People who use the service and their families are fully involved with their care plans. Staff were friendly and relaxed with the inspector and were keen to discuss their work and the care needs of people who use the service. The home and staff create a positive atmosphere, which people commented upon and which is welcoming to families and visitors. People who use the service commented, “The home here I honestly can’t fault it”. Relatives commented, “The staff are extremely kind and caring and we leave after visiting with complete confidence in her safety and comfort”. The home has strong links with supporting health professionals, who give good health support to people who use the service. A range of social activities takes place both within and outside of the home and this gives people who use the service the opportunity to meet, mix and socialise with others. The food provided is of a good standard, with good choice and variety. The dining rooms are well laid out with good staff attendance enabling people to have a pleasant and social mealtime. There is a complaints procedure and in addition the views of people who use the service are actively sought. They felt their views were listened to and acted upon. The home is furnished and decorated to a good standard and provides comfortable and pleasant surroundings for people who use the service. Individual bedrooms are well furnished and all are ensuite. Aids and adaptations assist people to move freely and independently around the home. The communal areas are well decorated and used for a range of social events. The home is well staffed with a skilled, consistent and trained staff team giving security to people who use the service. Staff recruitment and training records were clear and concise and contained relevant information. The vetting process helps protect people who use the service. The staff have a good Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 7 understanding of the individual needs of people who use the service, who were very complimentary about the staff. More than fifty percent of staff have undertaken National Vocational Training in Care at level Two or above and exceed the minimum standard; ensuring people who use the service receive care from a skilled and knowledgeable staff team. Staff have continued to undertake training and spoke of using this knowledge in their practice. People who use the service live in a home, which is well run and managed. What has improved since the last inspection? Individual care plans have continued to improve. Staff were more involved in planning and evaluating care and the plans. This helps staff give the people who use the service the care they need. The management overviews these plans and this helps to provide a consistent staff approach. The people who use the service are fully involved, where able, with their care plan. The décor and use of objects such as rummage bags, pictures and various materials have provided added interest for people with memory loss and were seen as a positive factor in the occupation and fulfilment of people who use the service. The social activities individual and home programme has been developed to provide individuals more opportunities for a social, leisure and fulfilled lifestyles. The provider and management have developed quality assurance and consultation with people who use the service, relatives, staff and supporting agencies ensuring they provide a service that meets the needs of individuals. Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 8 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. Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 9 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 Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 10 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): 3 6 not applicable People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service and their families have clear information they need to make an informed choice on where they live and have their needs assessed before admission to the home. EVIDENCE: The statement of purpose and service user guide are available to people who use the service and their families, these gave all relevant information. There are additional copies of this information at the entrances to the home. People who use the service and their families have the information they need to make an informed choice before their stay and receive a written agreement. Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 11 They have their needs assessed and are reassured how these needs will be met. Pre-admission assessments are undertaken and reflect the needs of the people who use the service. Care plans had good information to ensure that the home can meet the needs of the prospective service user. The manager is involved in the decisions and in the majority of instances visits the people himself prior to their admission. The service is efficient in obtaining a summary of any assessment undertaken through care management and working closely with the care management team. People who use the service and their relatives spoke of visiting the home prior to admission and that this was useful to reduce anxiety and make the settling in process easier. People who use the service commented, “I came straight from hospital but someone came and talked to me from the home” “I visited and had lunch and it just felt right for me” Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 12 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 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are having their health and personal needs met by the staff in the home and the staff are skilled in providing the care in a sensitive and dignified manner. They receive their prescribed medication in line with safe working practices. EVIDENCE: The key principle of the home is that people, who use the service, where able, are in control of their lives and they direct the service. Staff support individuals to lead purposeful and fulfilling lives as independently as possible. The care plans are developed with the individual based on a full and up to date holistic assessment. Three care plans were examined; they were of a good standard, with relevant risk assessments for the prevention of falls, nutrition, moving and assisting, continence promotion. The plans had been consistently Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 13 reviewed and updated on a regular basis. These plans were clear and easy to understand. The care plans showed that people who use the service have access to all NHS services and facilities if required. A number of assessment tools are in use. Daily reporting of peoples care was good with any changing health care being reviewed and updated in the care plan. Staff ensure that personal support is flexible and is able to meet changing needs and people have their wishes recorded on how they prefer their care. People who use the service commented, “The home cares for me well” “there is nothing they could do to improve”. Relatives commented, “Our mother has been in Sovereign Lodge one month in that time we are both delighted at the improvement in her health and wellbeing”. Health professionals commented, “A vast improvement since change in manager” “a welcome improvement to care given to residents” “appreciate the care given to clients with dementias”. The medicines in the home are well managed and safely disposed. A new medication system is in place and management and staff felt this was an improved system. A medication audit was not undertaken at this inspection. Staff were treating people who use the service with respect and dignity. Personal care was given in private. Staff used peoples preferred name at all times. Relatives and people who used the service were very complimentary about the staff in the home “they are all so kind” “they are always making sure you are fine but don’t treat you like you are daft” and they felt that they were able to have privacy in their own rooms. Sovereign Lodge DS0000000456.V376001.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. We have made this judgement using a range of evidence, including a visit to this service. Daily life and experience of activities meets people’s expectations of the service. People are well supported to live full and active lives, and keep links with family and the local community. EVIDENCE: Central to the homes aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community. People who use the service were generally happy and enjoyed being able to move freely around the home. Relatives and people who use the service felt that there was a developing range of social activities programme both within and outside of the home and this was thoroughly enjoyed by all. People had been enjoying ‘play your cards right’, bingo’ cards, dvd, shopping, sing a longs, darts, exercises. People who use the service, families and staff were planning and looking forward to a beach party at the home. Each individual has a ‘pen picture’, which outlines their interests and activities they Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 15 have taken part in on a daily basis. Individuals have the choice to follow their spiritual beliefs and attend church services if they wish. The home has sought the views of the people who use the service by questionnaires, meetings, individual social assessment and family reviews. Social activities staff are employed but each staff member had a holistic approach to meet individual needs. The daily activities that had been provided were varied and thoroughly enjoyed. People who use the service are encouraged to go to places in the local area and families are encouraged and supported to take them out and about. The local community participates in home events, which people said they really enjoyed. People who use the service commented, “I am enjoying my time here” “I hope my friend will also come to stay” “what do you mean can I please myself, this is my home” “it is the best move I have made” “I have nearly finished getting my room set up, got my fridge, kettle and now getting a microwave” “the handyman helped me with my wardrobe hanger making it easier so I can get my own clothes”. Relatives commented, “The home does well with the activities with the residents”, “we are made welcome whenever we visit” “my mum is so happy here with all her things around her”. People who use the service take control of their daily routines in simple but important ways including the time they get up, what and when they eat and how they spend their time. They said they are able to make choices about how they spend their day. The individuals’ bedrooms were personalised and people who use the service said they were very happy with the decoration and furnishings. People who use the service have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. It was observed that the meals served were good and people said they enjoyed the food, which was well cooked. Staff support was on hand. The tables were nicely set and lunch was seen as social occasion. Hot and cold drinks were readily available. A food survey had been undertaken in March 2009 with suggestions being addressed and menus reviewed. Pictorial menus are being developed to support people’s choice at mealtimes. People who use the service commented, “I am pleased with my meals” “the food is good” “you get plenty, sometimes too much”. Sovereign Lodge DS0000000456.V376001.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. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns, and have access to an effective complaints procedure and are protected from abuse. EVIDENCE: The home ensures that people who use the service and their relatives are aware of the complaints policy by making it available in a variety of places. Complaints are managed satisfactorily and the necessary action taken and recorded. The complaints procedure is displayed in the home and available to individuals and their families. The records of the complaints made to the home were examined and was satisfactory. People who use the service and their relatives spoken to know how and who to complain to and were confident that their concerns would be dealt with commenting, The manager stated that staff were aware of the whistle blowing policy and informing the manager of any incidents or issues of which there are concern. Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 17 Any causes for concerns had been appropriately managed through the safeguarding of adults procedures. Staff spoken to were aware of protecting people who use the service and whistle-blowing principles. The manager and the majority of staff had completed Protection of Vulnerable Adults training. Further staff training is planned. Sovereign Lodge DS0000000456.V376001.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 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enable people to live in a safe, well maintained and comfortable environment, which encourage independence. EVIDENCE: The home is purpose built to provide care for a range of need. The location and layout is suitable for the people who use the service. The home is now divided into two units, one for people with memory loss and the other for frailer older people. There are communal areas that are shared for social and leisure events. There are lounges and dining rooms. These are Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 19 pleasantly decorated and furnished. New furniture had been purchased for communal areas and bedrooms and redecoration throughout. People who use the service were able to move freely around the communal areas and there was a range of television and audio equipment available for their use. The décor and use of objects such as rummage bags, pictures and various materials have provided added interest for people with memory loss and were seen as a positive factor in the occupation and fulfilment of people who use the service. Individuals are involved in personalising their own rooms. The rooms are of a high standard, ensuite, the fixtures and fittings are of a good quality, well maintained and adapted to meet the wishes of the individual. There are assisted bathrooms and showers on each unit, toilets near to all communal areas as well as ensuite facilities in each bedroom. People who use the service were very positive about the home. There are additional services such as a coffee lounge, hairdressers and sensory room. The home was extremely clean and has good hygiene practices. Relatives commented, “Sovereign Lodge is always clean” “clean and tidy”. Sovereign Lodge DS0000000456.V376001.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. We have made this judgement using a range of evidence, including a visit to this service. The manager ensures there are adequate numbers of staff on duty that have appropriate skills and experience to care for the people who use the service. The recruitment processes in place protect people who use the service and external and internal training takes place providing a skilled, consistent staff team. EVIDENCE: Staffing rotas showed that there are enough staff are on duty to meet the necessary staffing levels for current number of people who use the service. When sickness and staff holidays occur home staff provides cover. Agency staff are not used. There has been a considerable staff turnover, but this has now been resolved with full staff compliment which provides consistent care for people who use the service. The home aims to operate with a one staff to seven service user ratios during the day and one staff to ten service users during the night. Senior care staff are undertaking team leadership training. Management and good ancillary support is also on hand. There is daily kitchen and domestic support. Social Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 21 activities staff work over the five days with Saturday socials held three weekly. Staff have experience on working on all units enabling a consistent approach to care. People who use the service commented, “The staff do all they can for you they are always busy” “they are always pleasant and courteous”. Relatives commented, “everything is fine when they are fully staffed but they are quite often short staffed” “Ray the manager has improved things” “staffing is much better now”. Staff commented, “Treat everyone with respect and the motto the staff use in the home is ‘if it is not good enough for your family it is not good enough for mine’ and to treat residents the way you want your mam or dad treat”. Three staff recruitment files across all grades were examined and were satisfactory. Staff undertake induction, mandatory training, National Vocational Qualifications in Care and other training. This was clarified from the sample of records inspected and discussions with staff. Staff spoke knowledgably about the individual needs of people who use the service. Twenty three staff had completed NVQ two or above and an additional seven were undertaking this course, exceeding the minimum standard of 50 of qualified staff. Each staff member has an individual training plan and receives an annual appraisal. Regular staff meetings are held for management, carers (day and night) and ancillary staff and these were documented. Sovereign Lodge DS0000000456.V376001.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): 31,33 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service live in a home, which is well run and managed by an experienced and qualified person. The manager has good systems in place to organise the home taking into account the needs and wishes of the people who use the service. Good quality systems have been established and are being developed. EVIDENCE: The registered manager has the Registered Managers Award and National Vocational Qualification in Care (level 4), as well as many years experience and Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 23 supporting training. The manager has undertaken additional training in health and safety, leadership and management, safeguarding investigations, dementia, mental capacity and deprivation of liberty. The manager is only responsible for Sovereign Lodge. The manager has an open and inclusive style that was commented upon by staff, residents and relatives. He undertakes daily walkabout to talk to people who use the service, staff and visitors, has an open door policy and holds weekly evening surgeries for any queries. The people who use the service and staff made positive comment about the provider, manager and staff team; they gave examples of improved practices and of the staff team taking time to listen and respond to any concerns they may have. Regular meetings had been held for people who use the service, relatives and staff to discuss and review practices and the running of the home. Three monthly questionnaires are given to people who use the service, relatives and any supporting service. These are reviewed and any issues acted upon and feedback given. The providers’ quality assurance and audit systems are comprehensive covering areas such as medication, home manager audit, catering. Weekly provider visits are undertaken with good written reports and any issues addressed. The home was well maintained with maintenance contracts in place. Accidents are recorded effectively with accident analyses being completed and risk preventions being undertaken to safeguard people who use the service. Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 24 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 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 25 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 Sovereign Lodge DS0000000456.V376001.R01.S.doc Version 5.2 Page 26 Care Quality Commission Yorkshire and Humberside St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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