Care Home: Ashdown Lodge

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What the care home does well People have a comfortable well maintained home to live in and have private accommodation, which they have made their own. People living at the home have told us that the staff are very kind and "can`t do enough for you." The manager wants to make sure that people who come to live at the home receive the care that they require and so ensures that peoples needs are assessed prior to them moving into the home and that they are then involved in putting together a plan of care which will meet their needs. There is a quality assurance plan in operation, which takes a different aspect of the service into consideration each month, and people have told us that feedback given has changed things for the better. Staff tell us that they are well supported and have opportunities to improve their skills by attending courses, which help them to do their job and achieve qualifications, which recognise their competences. What has improved since the last inspection? There have been continued improvements to the environment with bedrooms being redecorated as they become vacant and bedroom furniture and carpets being replaced if needed. Monthly checks for health and safety are being carried out and documented. Menus are being reviewed more often and people living at the home have been able to influence changes to the menu. Fortnightly group physiotherapy group has been set up at no extra cost to people who live at the home. Staff tell us that the management of the home has improved with the new manager in place. What the care home could do better: To ensure that people living at the home are fully protected all people employed to work at the home must have a CRB and POVA Disclosure carried out by their current employer. CARE HOMES FOR OLDER PEOPLE Ashdown Lodge 2 Wendy Ridge North Lane Rustington Littlehampton West Sussex BN16 3PJ Lead Inspector Mrs Diane Peel Unannounced Inspection 16th April 2008 10:00 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 Ashdown Lodge DS0000014371.V362221.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. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashdown Lodge Address 2 Wendy Ridge North Lane Rustington Littlehampton West Sussex BN16 3PJ 01903 785251 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 Janet Tucker Mrs Jean Bulley Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Ashdown Lodge DS0000014371.V362221.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: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - (OP) The maximum number of service users to be accommodated is 13. Date of last inspection 5th July 2006 Brief Description of the Service: Ashdown Lodge is a care home, which is registered to accommodate up to thirteen residents in the category (OP) old age, not falling within any other category. It provides personal care only. Ashdown Lodge is a semi detached two-storey property, which provides accommodation in thirteen single bedrooms located on the ground and first floors. A vertical passenger lift provides access to all floors. A dining room, a lounge, and a small library are located on the ground floor. There is well maintained garden, located to the rear of the property, which can be used by residents. The property is located in a residential area of Rustington close to local shops. Mrs Janet Tucker privately owns the service and the registered manager is Mrs Jean Bulley The current fees are £499 to £525 per week Ashdown Lodge DS0000014371.V362221.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 3 stars. This means the people who use this service experience excellent quality outcomes. This unannounced visit to Ashdown Lodge was carried out by Mrs Diane Peel on the 16th April 2008. During this visit the intended outcomes for 31 standards were assessed; these included the key standards for care homes providing a service to older people. The Annual Quality Assurance Assessment (AQAA) was returned to The Commission for Social Care Inspection (CSCI) prior to this visit to the home and this was used to address areas of improvements with the manager. Have Your Say surveys were returned to us by six people living at the home and five staff working at the home prior to the visit. Everybody returning surveys had positive things to say about Ashdown Lodge and most people made some comment about the improvements, which have been made since the home had a new manager. During the course of the visit we met many of the people living at Ashdown Lodge and joined people living at the home for lunch to find out more about what its like to live there. A case tracking exercise for two out of the ten people living at the home was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met. Staff were spoken with during the visit and observed during their interaction with people living at the home. What the service does well: People have a comfortable well maintained home to live in and have private accommodation, which they have made their own. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 6 People living at the home have told us that the staff are very kind and “can’t do enough for you.” The manager wants to make sure that people who come to live at the home receive the care that they require and so ensures that peoples needs are assessed prior to them moving into the home and that they are then involved in putting together a plan of care which will meet their needs. There is a quality assurance plan in operation, which takes a different aspect of the service into consideration each month, and people have told us that feedback given has changed things for the better. Staff tell us that they are well supported and have opportunities to improve their skills by attending courses, which help them to do their job and achieve qualifications, which recognise their competences. What has improved since the last inspection? What they could do better: To ensure that people living at the home are fully protected all people employed to work at the home must have a CRB and POVA Disclosure carried out by their current employer. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashdown Lodge DS0000014371.V362221.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 Ashdown Lodge DS0000014371.V362221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into Ashdown Lodge have sufficient information about the home to make a decision if it is right for them and they have their needs assessed prior to them moving into the home so that they are assured that the home can meet their needs. EVIDENCE: The people living at Ashdown Lodge who we spoke to during our visit told us about the process of finding a care home and how they had come to live at the home. For the majority spoken with, their sons, daughters or other relatives had been to look at the home for them and recommended the home. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 10 One person said “ my sons looked at a few homes and they said this one was the best.” Five out of the six Have Your Say surveys returned to us told us that people had had enough information about the home prior to moving in to decide if it was the right place for them. The other person felt that if they had been healthier at the time they would have looked at others. The home has a Statement of purpose and Service User Guide/Handbook, which is currently being updated. We were shown this information during our visit to the home and the amendments, which were being made. During our visit we looked at a pre assessment carried out for the last person who had moved into Ashdown Lodge. The assessment had been carried out prior to the date of this person moving in. The manager told us that she or the deputy manager carries out assessments and this can be in the persons own home, hospital or wherever they are at the time. The Annual Quality Assurance Assessment returned to us prior to our visit to the home states that “a full assessment of need is carried out before an agreement is entered into.” A person living at the home who spoke to us during our visit told us that that “someone from the home asked them questions about themselves and what they could do and what they needed help with.” The manager told us that when they have a room vacant they can offer it for respite care so that people can come and stay for short periods of time. Ashdown Lodge does not provide intermediate care. Ashdown Lodge DS0000014371.V362221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at Ashdown Lodge make decisions about the care they receive and know that their health care needs are being addressed so that they can retain their independence for as long as possible. EVIDENCE: We looked at the care plans for two out the ten people living at the home during our visit to see how peoples assessed needs had been transferred into a care plan and then we talked to people about how their needs were being met. Each area of need documented in the care plan identified how the need was to be met and what assistance and support was needed from the care staff and Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 12 other health care professionals whilst still enabling people to retain independence. An example of this was seen during the case tracking activity where it had been identified during a discussion with a healthcare professional that speech therapy would enhance that person’s quality of life. A referral had been made and on the day of our visit the speech therapist was visiting this person at the home. Where individual areas of risk had been identified risk assessments had been carried out and plans in place to best avoid the risk. We were told by the manager and in the AQAA returned to us that that there are monthly discussions with the people who live at the home about their care plans so that people are involved in “ stating their needs and preferences to what personal care they require, when and how if possible.” Four out of the six people returning Have Your Say surveys to us told us that they usually got the care and support that they needed and two people told us that they always get the care and support that they needed. Care plans observed had been updated monthly and there were daily recording to record people’s welfare and social activities. When asked the question “ are you given up to date information about the needs of the people you support or care for (for example in the care plans)?” all five staff returning Have Your say surveys to us reported that they did, always and one person said. “ Care plans are updated every month.” Comments received from people living at the home were:” the support is 100 also for care I have no problem at all” and “ very helpful staff.” People spoken with on the day of our visit told us that they were “very well looked after” and “ they talk to us about how we want things done and then if we want to change something they are flexible.” Care records showed us that people have access to other healthcare professionals such as chiropodist, opticians, physiotherapist, and hearing aid specialists to meet their medical needs and discussions with people living at the home confirmed that they could carry on having their own doctor if they wanted and would see them in the privacy of their rooms. The manager told us that nobody at the home currently manages their own medication and that there was nobody receiving controlled drugs. Medication is supplied by a local pharmacist who also provided the home with advice and support. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 13 Medication was observed to being stored in a locked cupboard, which also included a lockable metal cabinet. The home users a monitored dosage system, which is supplied on a monthly basis with any unused medication, being returned at the end of the month. We were told that records of returned medication are kept by the home. Medication records observed were clear and up to date. The manager told us that two senior staff had medication handling training and another two staff are undertaking training. Observation of practices during our visit confirmed that staff treat people living at the home with respect and ensure their privacy maintained. They address people, as they prefer to be addressed and treat people as individuals respecting their rights to remain as independent as possible. Ashdown Lodge DS0000014371.V362221.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The lifestyle residents experience matches their expectations and preferences, so that their social, cultural, religious and recreational interests and needs are met. EVIDENCE: People spoken with during our visit to Ashdown Lodge were very satisfied with their lifestyle at the home. One person told us “ I can do what I want. I Get up when I want, go to bed when I want, have my meals where I want.” A person living at the home who returned a Have Your Say survey to us told us “ I prefer to stay in my room where I can carry on my correspondence, read or watch anything interesting on TV.” Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 15 The six people returning Have Your Say surveys told us that they usually have activities arranged by the home that they can take part in. The AQAA returned to us by the manager told us that activities on offer include “ knitting, manicures, craft, painting, a monthly film afternoon, board games, armchair basket ball, magnetic darts and cards” and stated “ we have a book with them listed and pictures to show residents what is on offer. One person living at the home told us during our visit that they liked to do jigsaw puzzles and had a paint by numbers in their room and another told us about the books which the local library supplies them with. We were told in the AQAA returned to us that fortnightly physiotherapy sessions have been set for people who live at the home. Another person told us that they like to go out to the shops in Rustington with their daughter. One of the people living at Ashdown Lodge had been able to bring their dog with them to live at the home and during our visit we saw how this had benefited other people living at the home to have a pet around them to make a fuss of. During our visit to the home the person owning the dog took dog to the Dog Groomers. The AQAA returned to us told us that as further improvements to activities it is hoped to have a green house in the garden to encourage people to have their own plants to care for and that they would also like to set up cooking sessions for people who live at the home. The manager told us during our visit that one person had seen a pattern for a teddy bear which they wanted to knit in one of the books from the library and that they were now knitting the bear and that other people liked to help out in the kitchen. The manager also told us that there is currently no regular visiting outside entertainers coming to the home but the next subject on the monthly quality assurance surveys is activities and entertainment and if people request outside entertainers this will be responded to. Ashdown Lodge operates an open visiting policy and people living at the home spoken with during our visit confirmed that their visitors could visit at any time. The visitor’s book on display in the hallway records regular visitors to the home to see people living there. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 16 The homes own quality assurance surveys carried out in January 2008 reported that people were satisfied with arrangements for visiting. Five out of the six people returning Have Your Say surveys to us told us that they always liked the food at the home and one person said that they sometimes liked the food. We saw the homes own quality assurance surveys about food during our visit to Ashdown Lodge, which showed us that people living at the home had recently been consulted about the standard of food and choices available. Generally people had been satisfied and some suggestions had been made which the manager told us had been taken seriously, for example one person had commented that they didn’t like fish in sauce so it had been decided not to put it on the menu as frequently. We joined people eating in the dining room for the main meal of the day, which were sausage casserole, mash potatoes, swede and cabbage followed by pear crumble and custard. The people who we sat with told us about the meals which are not always prepared by a cook because they don’t have a full time cook. We asked about how they know what is for the meal and we were told, “one of the carers comes round and tells us what the main course is and what we could have as an alternative.” People living at the home also told us that they had breakfast in their rooms brought up on a tray and that they could have what they liked. The AQAA returned to us prior to our visit told us that there is a monthly review on breakfast choices. Discussion with the manager confirmed that care staffs also carry out cooking within the home and for this reason most had done a food hygiene course. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear so that people know what to do if they have a complaint and how they should expect their complaints to be dealt with. EVIDENCE: Ashdown Lodge has a complaints procedure a copy of which is included in the Service User Guide. All six people living at the home who returned Have Your Say surveys to us told us that they knew how to make a complaint and who to speak to if they were not happy about something. All five staff returning surveys to us told us that they knew what to do if a person living at the home, their relative or advocate had concerns about the home. The AQAA received from Ashdown Lodge told us that the home has not received any complaints since we last visited. The manager confirmed this during our visit. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 18 We have not had any concerns brought to our attention about the management of the home. The manager told us that she has a copy of the most recent West Sussex Multi Agency Safeguarding procedures in addition to the homes own procedures and that she has been on a recent safeguarding event held by the local authority. The majority of staff have had safeguarding training and we were told that this is also covered in the Skills For Care induction programme in use at Ashdown Lodge. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ashdown Lodge is comfortable, clean and well maintained so that people have a home from home environment to enjoy. EVIDENCE: All areas of the home that were seen have been well maintained, decorated to a good standard and are in keeping with a comfortable family home. The communal areas are light and spacious. The furniture and fittings in the lounge and dining areas are modern and above average quality. A cosy homely Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 20 effect has been created by the arrangement of the furniture with a focal feature of a fireplace with a glowing flame effect fire. People living at the home that we spoke with during our visit were very pleased with the environment and assured us that it was always kept clean. Four out of the six people who returned have Your Say surveys to us told us that the home is always kept fresh and clean and two people said that it is usually kept fresh and clean. People living at the home have made their private accommodation their own by having on display items which they have brought to the home and some people have also got their own furniture in their rooms. We looked at two vacant rooms, which had recently been redecorated, new carpet in place and for one bedroom new furniture. The manager told us that when a room becomes vacant it is redecorated and furniture and carpets replaced if needed. We saw daily records during our visit, which recorded the delivery of furniture to Ashdown Lodge for a person who had recently moved into the home. Fire risk assessments were observed in care plans and the manager told us that environmental risk assessments are currently being undertaken with the assistance of an outside professional. During the time we were at Ashdown Lodge the home was very clean and we saw that alcohol gel is provided around the home for people to use if they wish. Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Outstanding CRB and POVA disclosures must be applied for by this employer so that people living at the home know that they are in safe hands all times. EVIDENCE: There were ten people living at Ashdown Lodge on the day of our visit and there were two care staff on duty at the time of this visit, supported by a part time cook and the manager. The rota for the week commencing 14/4/08 seen in the kitchen confirmed consistent staffing levels with the manager also working directly with people living at the home in addition to dedicated management administration time. The recruitment records of two staff were viewed during the visit, which included the most recently employed person. There was evidence of current Criminal Record Bureau (CRB) and Protection of Adults (POVA) in place for the person most recently employed and the Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 22 manager confirmed that it is normal practice to get POVA First clearance before anyone starts work at the home. It was observed that the CRB clearance for the other person who had worked at the home for a number of years was not carried out by Ashdown Lodge and through discussion with the manager it was established that two students employed after school hours did not have CRB and POVA disclosures. This matter was discussed with the manager at the time of the visit who has agreed to rectify the matter. A job application was on file, two references; evidence of verification of identity had been confirmed for both people whose recruitment documents were viewed. When asked in the Have Your Say surveys “ Did your induction cover everything you needed to know to do the job when you started? two staff returning surveys reported very well and three staff reported mostly. All five staff returning surveys reported that that they were being given training relevant to their role, which helped them understand and meet the needs of individuals who they work with and keeps them up to date with new ways of working. All five staff returning surveys said that they regularly met with their manager for support and discussion about how they work. Comments from staff included in surveys to us were: “Continuing with level 4 NVQ.” “Since we have had a the new manager we have regular supervisions, new training courses.” “I have completed my Dementia Care ASET course and now doing my infection control. Have NVQ 2 and I will be doing my NVQ 3 in Sep 08.” Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home and their relatives can be confident that the manager wants to run the home in the best interests of the people that live there, but to achieve this must ensure that all staff have CRB and POVA disclosures obtained for this employment. EVIDENCE: Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 24 The manager was registered with us in December 2007 and has worked within the care sector for many years as a nurse or deputy manager and has previously been a registered manager of a nursing home. She has the Registered Managers Award and is also an NVQ assessor and verifier. Comments received from staff in Have Your say surveys returned to us included: “Since we have had a new manager things have gone from strength to strength. It is a very nice home to work for. The manger is always here to help and support our needs as well as the individuals that are in the home.” “ Since we had the new manager we have regular supervision. A better place to work really, more team work.” During our visit we saw the results of the homes own quality assurance surveys, which are carried out monthly covering a different aspect of the service. The manager told us about how this has already made some changes, e.g. changes to menus. We were also told that the registered provider continues to visit regularly and carries out audits to make sure that the home continues to deliver a good service to people who live there and writes a report about the visits. People living at the home who we spoke with told us that they felt part of the home and “we all get on well together.” Staff supervision and appraisal documentation were observed in the staff records viewed during our visit. The manager told us that the service does not look after money for anyone living at the home. People have a secure facility in their rooms for any money that they want to keep and any expenditure not included in the fees are invoiced to the individual, their next of kin or their advocate. Information provided in the AQAA returned to us prior to our visit reported regular servicing and testing of equipment and we saw during our visit that environmental risk assessment were in place for peoples own rooms. We were told that further environmental risk assessments are being carried out. Ashdown Lodge DS0000014371.V362221.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 X 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 3 3 4 3 3 4 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 3 X 3 X 3 3 X 3 Ashdown Lodge DS0000014371.V362221.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 OP29 Regulation 19.1 Requirement Outstanding CRB and POVA disclosures must be evidenced as applied for by this employer. Timescale for action 01/05/08 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 Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ashdown Lodge DS0000014371.V362221.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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