Care Home: Ashton Lodge

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What the care home does well People living at the home feel that the standard of food provided is very good. Many people commented that they are given sufficient in quantity and that they find the meals tasty. People are given a choice at mealtimes; one person said that if they didn`t like the things that were on offer the cook always made them something else. Staff are also good at making sure that if a person needs food supplements, that there are plenty in stock and that the person is offered these. Information that people can be given about the service, prior to deciding if they wish to move into the home is good. These documents are called the statement of purpose and service user guide. They are written in a way that is easy to understand. They let the reader know about the qualifications of staff, room sizes and services available for example. This means that people areAshton LodgeDS0000014990.V377594.R01.S.docVersion 5.2clear what they should expect if they decide to move in to the home, and they provide a useful aid in helping them come to this important decision. When staff are recruited to care homes there are safety checks that need to be done, this helps to protect the people living at the home. Management must make sure for example, that they receive at least two references and carry out a check known as a Criminal Records Bureau check, this helps them to decide if the person is going to be suitable to work with vulnerable people. We looked at all the files for the most recently employed staff and found that all the required checks had been done before those staff had been allowed to work. What has improved since the last inspection? When a person was at risk of falls they now had a risk assessment about this, the assessment outlined in the person was at low, medium or high risk. This means that staff would know if special measures and support would be needed, to help prevent the person falling. Staff no longer carryout nursing procedures, unless they have been trained and assessed by the District nurse, as being competent to do so. More information has now been written into care plans for people who have dementia, since we last inspected. This information is an improvement however further development is still needed in the documents known as care plans. What the care home could do better: There are several areas that need to change or improve, these include: Records maintained by staff about the daily development and changes to the people living at the home were not stored securely. Information is written in A4 sized books, but these are left in the various lounge areas on tables for example. There is confidential information within these books, and anyone can access this information, this does not comply with data protection or uphold the privacy of the people living at the home. We looked at two of the areas where medication is stored in the home and undertook random audits of medication on five people. We acknowledge that four of the audits showed that records were correct and balances of medication were accurate, however for one person one of their medication supplies was incorrect by 16 tablets within the current 28 day medication cycle. This is not safe for that person.Ashton LodgeDS0000014990.V377594.R01.S.doc Version 5.2 We saw a denture that was on an unoccupied table in one of the lounges and pointed this out to staff, it was then removed. We checked at the end of the inspection if the owner of the denture had been identified, they had not. During this time the midday meal had been served, so there was a person who had been given their main meal, when they did not have one of their dentures. Key inspection report CARE HOMES FOR OLDER PEOPLE Ashton Lodge Ashton Road Dunstable Bedfordshire LU6 1NP Lead Inspector Katrina Derbyshire Key Unannounced Inspection 10th September 2009 12:05 DS0000014990.V377594.R01.S.do c Version 5.3 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. Ashton Lodge DS0000014990.V377594.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 Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashton Lodge Address Ashton Road Dunstable Bedfordshire LU6 1NP 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 673331 F/P 01582 673331 resicarehomesltd@btconnect.com Resicare Homes Limited Manager post vacant Care Home 54 Category(ies) of Dementia - over 65 years of age (54), Old age, registration, with number not falling within any other category (54), of places Physical disability over 65 years of age (54) Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2008 Brief Description of the Service: The home is situated in a residential street, close to Dunstable town centre. The home was extended in 2005 and now provides 54 beds in single and double rooms, 4 lounges, and a number of communal toilets and bathrooms. The home is arranged with the bedrooms on all three levels and communal areas on the ground floor. For operational reasons the home is divided into three areas, grouping people according to their needs, but still respecting freedom of movement throughout the home. A pleasant garden is easily accessible and was well used by the service users in the summer months. The home charges between £495.00 and £520.00 per week depending upon the care and support required by people who use the service. This rate was detailed within the service user guide that was examined on 10th September 2009. This fee does not cover hairdressing, private chiropody and dry cleaning. Ashton Lodge DS0000014990.V377594.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 was an unannounced key inspection carried out on the 10th September 2009. The care of four people was looked at in detail and this is known as case tracking. Tracking people’s care is the methodology we use to assess whether people who use social care services are receiving good quality care that meets their individual needs. Through discussion, observation and reading records, we track the experiences of a sample of people who use a service. During the visit the communal areas of the home were seen alongside some of the individual rooms. Time was spent with some of the people who live at the home in two of the sitting areas. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The management’s submission of documentation was also considered prior to the site visit. The focus of this inspection was to look at the key standards. What the service does well: People living at the home feel that the standard of food provided is very good. Many people commented that they are given sufficient in quantity and that they find the meals tasty. People are given a choice at mealtimes; one person said that if they didn’t like the things that were on offer the cook always made them something else. Staff are also good at making sure that if a person needs food supplements, that there are plenty in stock and that the person is offered these. Information that people can be given about the service, prior to deciding if they wish to move into the home is good. These documents are called the statement of purpose and service user guide. They are written in a way that is easy to understand. They let the reader know about the qualifications of staff, room sizes and services available for example. This means that people are Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.2 Page 6 clear what they should expect if they decide to move in to the home, and they provide a useful aid in helping them come to this important decision. When staff are recruited to care homes there are safety checks that need to be done, this helps to protect the people living at the home. Management must make sure for example, that they receive at least two references and carry out a check known as a Criminal Records Bureau check, this helps them to decide if the person is going to be suitable to work with vulnerable people. We looked at all the files for the most recently employed staff and found that all the required checks had been done before those staff had been allowed to work. What has improved since the last inspection? What they could do better: There are several areas that need to change or improve, these include: Records maintained by staff about the daily development and changes to the people living at the home were not stored securely. Information is written in A4 sized books, but these are left in the various lounge areas on tables for example. There is confidential information within these books, and anyone can access this information, this does not comply with data protection or uphold the privacy of the people living at the home. We looked at two of the areas where medication is stored in the home and undertook random audits of medication on five people. We acknowledge that four of the audits showed that records were correct and balances of medication were accurate, however for one person one of their medication supplies was incorrect by 16 tablets within the current 28 day medication cycle. This is not safe for that person. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.2 Page 7 We saw a denture that was on an unoccupied table in one of the lounges and pointed this out to staff, it was then removed. We checked at the end of the inspection if the owner of the denture had been identified, they had not. During this time the midday meal had been served, so there was a person who had been given their main meal, when they did not have one of their dentures. 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. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 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 Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 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): 1,3 & 6 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. Information available to people prior to admission about the home is sufficient to assist them in making a decision on whether to move into the home. EVIDENCE: Through our selection of people for case tracking we looked at people who had recently moved into the home at this visit. The care files examined included pre-admission assessment. Assessments included information from visiting the person wherever he or she was living prior to admission and information from any referring social worker or health professional. The information given was recorded on documents that had varying sections including physical, Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 10 social, emotional and psychological needs of the people. The information was now clear and linked to the care plan. People spoken with as stated at the last inspection confirmed that they had been asked about themselves and they felt that they had been able to part of that process. The statement of purpose and service user guide was examined; each individual care folder had a service user guide in place. The document provided information on the staffing, accommodation and services available at the home. People had been offered a copy of this. Feedback from people living at the home indicated that they felt that they had been given sufficient information about the service, before moving into the home. Intermediate care is not provided at the home. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 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. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Inconsistencies in the standard of care planning and medication means not everyone receives continuity of care and the support that they need to meet their needs in full. EVIDENCE: Care records were examined within the individual folders. The standard and quality of care plans and record keeping was found to be inconsistent. The care plans were all typed documents. One person had a plan in place for example that advised staff that the person needed assistance with their personal care, this was linked to their assessment and on speaking to staff they confirmed that they knew this. However another person had a plan in place as they were at risk of falls; however there was no specific guidance to staff to indicate the Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 12 measures they should take to reduce the risk of falls. The only information was they were at risk and why, but no preventative measures were written to direct staff. Another person with diabetes who had insulin to help control this did not have any guidance to staff in regards to this. There was no information about their diet, times, what staff should do in the event of the person becoming unwell for example. We spoke with one staff member who was working in the large lounge and asked them to show us if there was any further information about guidance that they should follow, they replied no. We looked at two of the four areas where medication is stored in the home and undertook random audits of medication on five people. Four of the audits showed that records were correct and balances of medication were accurate, however for one person one of their medication supplies was incorrect by 16 tablets within the current 28 day medication cycle. A staff member who has responsibility for the ordering of medication was present during this time. On entering the large lounge it was noted that the books used by staff to enter the daily notes about the people living at the home were sitting on a table, on entering other lounges it was also noted that these books were unsecured as well. Confidential information is contained within the books; the current arrangements do not comply with the Data Protection Act. On entering the large lounge just before lunch was served we saw a denture that was on an unoccupied table in one of the lounges and pointed this out to staff, it was then removed. We checked at the end of the inspection if the owner of the denture had been identified, they had not. During this time the midday meal had been served, so there was a person who had been given their main meal, when they did not have one of their dentures. Information within the care records showed that people had access to health services. One person for example had needed to be seen by a Doctor and this had been arranged promptly by staff, a prescription had been written and staff had secured the medication the same day for the person. Two of the people we spoke with also confirmed that District Nurses visited the home most days, both stated that it was their experience that staff always helped them to access health services and support when they had needed to. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. People living at this home feel that the choice of meals provided are sufficient to meet their tastes and preferences. EVIDENCE: Several people spoke of the activities available to them and all advised that at times they felt that they had enough things to occupy them, however there were times when they felt that there was not anything for them to do. These people specifically commented that they would like to see more outings available, on speaking with the management in the home they confirmed that there had not been an outing yet in 2009. Documents examined showed that activities were provided but not fully consistent in their availability. Staff over the past several months had been fundraising to increase the amount of social activities available. They had purchased DVD players for each lounge to hold ‘film nights’. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 14 People were seen to receive visitors. Everyone as indicated at the previous inspection confirmed they were able to receive visitors when they wished and many would chose to see them in the privacy of their own rooms. Entries were also seen within people’s care records that demonstrated that the staff at the home would contact the nominated next of kin if there had been a change in their well being, one example of this was following an accident and the contact details had been recorded by the staff member. Options available to people in maintaining control, independence and choices in their lives remain, choice of meals, voting, choice of clothing, access to a complaints procedure and access to community healthcare support. People living at the home and records confirmed that the choices associated with people’s daily lives were available to them whilst living there. All the people spoken to stated that they enjoyed their meals. An observation of a meal was undertaken most people had chosen to eat this at the dining room tables. People had been offered two choices and their selection had been written down on a menu board. The most recent environmental health inspection found that there were sufficient standards in this area being maintained. In addition nutritional risk assessments were seen to have been undertaken for the people living at the home. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 feel they are listened to and their views are acted upon. EVIDENCE: The homes complaints procedure was examined. It advised the reader on how they could complain and information on how to complain was also detailed within the homes service user guide. No complaints had been received by the service since the last inspection at the time of this visit. Three of the people we spoke to, advised that they would feel comfortable raising any issue that they may have. One person gave an example where in the past they felt other people living at the home had been in their room, management had acted upon this and they now had their own key to their room. Records examined showed that staff had undertaken training in the safeguarding of adults. On speaking with staff they confirmed that they had undertaken this training and demonstrated a good level of understanding in this area. At the time of this inspection there was an ongoing investigation regarding a safeguarding referral made following information received by the Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 16 local authority. Management had acted upon this information whilst following guidance from their advisors in regard to employment law. At the time of this visit the conclusion or outcome of this is not known. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 17 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 accommodation provides a suitable environment for people to receive the care that they need and to live in. EVIDENCE: As reported at the previous inspection all areas that were seen were noted to be clean, tidy and odour free. The home has a maintenance programme and bedrooms are on a programme of being painted and recarpeted. Individual rooms are personalised and reflect the personality of the occupant. Housekeeping staff ensure soap dispensers are filled as part of the infection control measures in the home. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 18 People we spoke with reported that they were satisfied with their accommodation; everyone stated that they were ‘happy’ with their individual rooms. Again as reported at the last inspection the home is equipped with aids to help people maximise their independence, including raised toilet seats, grab rails and alarm call buttons. People who use the service who spend time in their own room had easy access to the call bell and confirmed staff responded to its use. Aids and adaptations that require maintenance checks have them conducted when necessary and records were inspected. The main entrance to the building was only accessible by ringing the doorbell and being granted access by staff. There is visitor’s book in place, which all visitors are expected to sign on entry. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Recruitment practices in the home are good and help protect the people living in the home. EVIDENCE: References are taken prior to staffs’ commencement and the relevant Criminal Records Bureau check is also carried out and evidence of this having been undertaken was seen. Certificates of qualifications are present within staff files. Evidence was also seen that steps had been taken to verify information and check on a persons employment history. Senior support workers, care assistants, catering and housekeeping staff are employed at the home. Rotas show that there are sufficient numbers of staff on duty throughout the day and night to meet the needs of the people at the home at this time. People confirmed that staff were available to help and assist them when they need help. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 20 Observation of the interaction between staff and people at the home was carried out throughout the visit. With the exception of one member of staff, all were seen to be polite and courteous. When staff assisted people to move for example, each step was explained to them and staff spoke in a supportive manner. One person said, “I find the staff very helpful, nothing is ever too much trouble”. Training records examined showed that staff had undertaken statutory training, including moving and handling, fire safety and food hygiene. Staff had also undertaken dementia awareness training since our last visit. However there remains a need for staff to receive training in the specific areas of need that people have that live in the home. For example in diabetes management and COPD, so that they have an understanding of the possible effects that these conditions can have on people and how they can support them. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is not registered with the Care Quality Commission. Monitoring and review of the standards of care through monthly reporting needs to be carried out, this will meet requirements and help improve standards at the home. EVIDENCE: Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 22 At the previous inspection a requirement was made that the manager of the service be registered with the Commission for Social Care Inspection. An application was submitted by her, but returned as it was not completed correctly in December 2008. She advised at this visit that she had re submitted this and was now awaiting her interview date with the Care Quality Commission. However we were also advised at this inspection that she had been covering another service within the company and will be the manager of that service. We were also advised that the Deputy manager had been managing this home on a day to day basis for the past two weeks, she was to be appointed as manager and would be submitting an application to be registered. We requested that this be put in writing to us, since the visit this written notification has been sent by the owner. Although an application had been submitted by the former manager (the processing of this is no longer wanted by the service), with the recent changes in management at the home, the requirement to submit and register a manager will remain as there remains a need to have a Registered manager in place. We have not deemed this to be an outstanding requirement as an application was submitted, so will assess this as a new requirement. Health and safety policies were in place. Records were seen that evidenced that required safety checks had been carried out relating to fire, gas and electrical equipment. Approved contractors had undertaken servicing of equipment, it was noted that several services were now due again in September 2009 we were advised that this was taking place later in the month. Questionnaires had been sent out by the service to seek the views of people living at the home and relatives in February 2009, we were advised that there was a limited response and these were then viewed. There had been no monthly visits undertaken as required by regulation 26. In view of the current safeguarding investigation and changes in management this required monitoring of the home must be carried out and a requirement has been made. The home does not deal with any finances for people who use the service but an itinerary of personal possessions is recorded and updated. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X N/A X X 3 Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 24 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 (1) Requirement Care planning must be person centred, making sure there is specific guidance for each assessed need that staff can follow to ensure continuity of care is given. When medication is administered to people who use the service it must be clearly recorded, if not given then reasons why must be recorded. This is to ensure people receive the correct levels of medication. Written records maintained about the people living in the home must be stored in a way that maintains the persons privacy and meets the requirements of the Data Protection Act. People must always receive the attention and support they need for them to maintain an acceptable level of well being. People must have their dentures especially when eating their meals. When a person has a specific DS0000014990.V377594.R01.S.doc Timescale for action 30/11/09 2. OP9 13(2) 31/10/09 3. OP10 17(1)(b) 31/10/09 4. OP10 12(4)(a) 31/10/09 5. OP30 18(1)(a) 31/12/09 Page 25 Ashton Lodge Version 5.3 6. OP31 8 need for example COPD or diabetes training in these needs must be provided to staff, this is to increase their understanding of the support that they should provide. The manager must submit a 15/11/09 completed application to be registered with the Care Quality Commission to demonstrate their fitness to practise. Monthly visits must be carried out by a suitable person to review and monitor the standards of care in the home. A written report must also be completed to document the review and record any actions taken. 31/10/09 7. OP33 26 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 OP12 Good Practice Recommendations Opportunities should be available for the people using the service to go out on trips if they wish to. Ashton Lodge DS0000014990.V377594.R01.S.doc Version 5.3 Page 26 Care Quality Commission Eastern 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). 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. 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