Care Home: Swan Lodge

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What the care home does well The home has a skilled and competent manager who has a good knowledge of the people living in the home including both their care needs and as individuals. The staff working in the home also know the residents well and use the knowledge to good effect when providing care. The manager has a good relationship with visiting professionals and she makes sure that she seeks advice and support from them to make sure that any actions taken on behalf of a resident are made in their best interest. The home has a very pleasant atmosphere and visitors are made welcome when visiting their friends or relatives. A number of relatives spoken to during the visit were positive about the care being delivered and those residents who were able to express their opinions were complementary about the staff and the way they are supported an example being the "staff are lovely" and "you couldn`t fault the care". Care planning is good and the records are detailed and up to date. Care delivery is managed well by the staff on a day to day basis and the staff were observed being kind and patient during all of the interventions and in the contact they have with them throughout the day. The residents were given good opportunities to make choices in how they live their lives. The manager is continuing to work at making the improvements identified as a result of the quality assurance process and is looking at "best practice" advice. What has improved since the last inspection? There have been improvements made since the last inspection including the deep cleaning of the kitchen floor and updating the fire risk assessment. The atmosphere in the home is very positive and the residents were very complementary about the staff and the way they are supported to live more active and fulfilling lives. What the care home could do better: No requirements were made as a result of this inspection. Three recommendations were identified. The manager should look further at how the care records are kept up to date to show the care that is given.Swan LodgeDS0000028821.V376022.R01.S.docVersion 5.2The remaining redecoration and refurbishment should be undertaken as planned to make sure that the home is a pleasant place for people to live. Also the way that the kitchen and care staff communicate should be reviewed to ensure that the meal times are as positive an experience as possible for the residents. Key inspection report CARE HOMES FOR OLDER PEOPLE Swan Lodge Kent Avenue Wallsend Tyne & Wear NE28 0JE Lead Inspector Suzanne McKean Key Unannounced Inspection 18th June 2009 09:15 DS0000028821.V376022.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. Swan Lodge DS0000028821.V376022.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 Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swan Lodge Address Kent Avenue Wallsend Tyne & Wear NE28 0JE 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) 0191 263 9434 0191 2621413 swan.lodge@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd manager post vacant Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Swan Lodge DS0000028821.V376022.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 with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP, maximum number of places: 46 The maximum number of service users who can be accommodated is: 46 1st August 2007 2. Date of last inspection Brief Description of the Service: Swan Lodge is a purpose built care home situated on the same site as another care home owned by the same company. The home provides nursing and social care for up to 46 older persons. There is also a contract with the NHS to provide 6 beds for the local GPs. The home has lounges, dining rooms and separate smoking rooms on each floor. All of the bedrooms are single and have en-suite facilities. There are a range of specialist bathrooms, showers and toilet facilities throughout the home. The first floor is accessible by stairs and a passenger lift and the grounds are readily accessible. There is ample car parking to the front of the home. The home shares the kitchen and laundry services with the adjacent home. Swan Lodge is well positioned for local transport and all local amenities. The fees charged by the home range between £422.90 and £557.00 depending upon the resident’s needs and service they receive. Additional fees are paid to the home via the nursing care element (free nursing care payment). There is information about the service through the service user guide containing the statement of purpose. A copy of the last inspection report from Commission for Social Care Inspection is available in the entrance to the home. Swan Lodge DS0000028821.V376022.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 two star – good service. This means the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken Summary: This is an overview of what the inspector found during the inspection. How the inspection we carried out:Before the visit we looked at:• The information we have received since the last visit on 17th June 2008. • How the service dealt with any complaints and concerns since the last visit. • Any changes to how the home is run. The providers view of how well they care for people. • The views of people who use the service and their relatives, staff and other professionals. The visit: An unannounced visit was made on 15th June 2009 and the visited lasted six and quarter hours. The visit was undertaken by the link inspector for the home. During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors. • Looked at information about the people who use the service and how well their needs are met. • Looked at the records which must be kept. • Checked the staff had the knowledge, skills and training to meet the needs of the people they care for. • Looked around the building and 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 the Regional Manager what we found. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 6 What the service does well: The home has a skilled and competent manager who has a good knowledge of the people living in the home including both their care needs and as individuals. The staff working in the home also know the residents well and use the knowledge to good effect when providing care. The manager has a good relationship with visiting professionals and she makes sure that she seeks advice and support from them to make sure that any actions taken on behalf of a resident are made in their best interest. The home has a very pleasant atmosphere and visitors are made welcome when visiting their friends or relatives. A number of relatives spoken to during the visit were positive about the care being delivered and those residents who were able to express their opinions were complementary about the staff and the way they are supported an example being the staff are lovely and “you couldn’t fault the care”. Care planning is good and the records are detailed and up to date. Care delivery is managed well by the staff on a day to day basis and the staff were observed being kind and patient during all of the interventions and in the contact they have with them throughout the day. The residents were given good opportunities to make choices in how they live their lives. The manager is continuing to work at making the improvements identified as a result of the quality assurance process and is looking at best practice advice. What has improved since the last inspection? What they could do better: No requirements were made as a result of this inspection. Three recommendations were identified. The manager should look further at how the care records are kept up to date to show the care that is given. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 7 The remaining redecoration and refurbishment should be undertaken as planned to make sure that the home is a pleasant place for people to live. Also the way that the kitchen and care staff communicate should be reviewed to ensure that the meal times are as positive an experience as possible for the residents. 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. Swan Lodge DS0000028821.V376022.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 Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3, the home does not provide intermediate care 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. Good pre-admission assessments carried means that the residents can be confident that they can have their needs met and that the home will be prepared for the to move in. EVIDENCE: The care plans contain comprehensive pre admission assessments which are carried out before any resident is admitted to the home. The care manager’s pre-admission assessment is kept in the. Residents who need nursing care are assessed by the NHS nurse assessor, these written assessments were also kept on record. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 10 The company have a very comprehensive assessment document which has recently been undated. This covers all of the areas of a persons needs and their previous lifestyles so that the staff can put together an accurate picture o of the resident. These records form the basis of the care planning process and these are added to during the placement. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good individual care planning and recording makes sure that the people living in the home have their needs met and they are treated with respect and their privacy maintained. EVIDENCE: Each resident has an individual care plan in place. These identify their care needs and how they are to be met. These are based on an admission assessment, which is then added to during the placement. The care plans contain enough information regarding the needs of the resident to allow staff to give the necessary care. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 12 There are risk assessments available for nutrition, wound care, moving and assisting, and continence promotion. The plans are regularly reviewed and updated to make sure that they contain up to date and accurate information. The care plans show that the residents have access to all NHS services and facilities. The records of fluids being given or offered residents who are at risk of becoming de-hydrated were not all up to date. The manager was confident that this was a recording error and not an omission in the care, however staff should be reminded of the need to keep good records to show the care being given. There was a good range of pressure relieving mattresses in use for the prevention of pressure sores. The records for those residents who have pressure ulcers or other wounds showed how they were being managed. These were appropriate, detailed and up to date. External advice was being sought from NHS advisors for specific care needs for residents as necessary, recent examples have been continence and tissue viability advisors. The staff have undertaken additional end of life care training and others are scheduled to receive it in the near future. The home has equipment for administering medicines through a syringe driver and the staff feel confident in its use. The manager and senior staff are currently developing the procedures for caring for people at the end of their lives. The systems for managing medicines in the home are appropriate. The staff record the medicines being ordered. The prescriptions are then checked on receipt from the General Practitioners and are then sent to the Chemist for dispensing. The medicines are checked again when received into the home so that any errors can be picked up. The home has a contract with a Pharmacist, which included giving advice as necessary. No residents are currently managing their own medication. There is a contract in place for the disposal of those medicines no longer needed by residents. The contract is part of the pharmacy agreement. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. Residents are given good opportunities to take part in varied and individualised social activities, and are supported to maintain contact with family, friends and the local community in way which is suited to the individual’s needs. EVIDENCE: The home employs an activities co-ordinator, known as a Personal Activities Leader. She works twenty one hours per week and the manager is currently recruiting a person to undertake an additional seventeen hours. There are social care assessments in the care plans and the records of the activities that the residents take part in are very well recorded including how much they enjoyed it. The activities co-ordinator is involved in organising in house activities carpet bowls, scrabble, and videos. A number of residents Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 14 have been out individually and the manager is arranging a trip out using the company minibus which is kept at another home. Due to the dependency level of some of the residents a number of the activities offered are less active and provided on a more one to one basis. This is now sufficiently developed to offer individualised activities for the residents in line with their social assessment. The records of the activities provided are more detailed and shows on an individual basis what activities the people living in the home are enjoying. The residents described the ways they are encouraged to 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. Staff confirmed that they assist residents to make choices about how they spend their day. Residents have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. Relatives are given information within the residents’ guide about visiting arrangements. Residents said they were satisfied with the arrangements for visitors and that staff welcome them. The food served on the day of the visit was mince or sausage pie served with a choice of vegetables. This was a change from the menu and the staff were not aware that it had been changed from the day before when the residents had been asked for their choice. The staff managed the change quite well, but better communication on the day would have made the meal time a more pleasant experience for everyone. The pudding was also changed to sponge pudding or scone from fruit and ice cream. Again the staff serving were not informed of this before the meal time. All residents seemed to enjoy the food served, an example of this was one who said, “the food is always nice” and “try the food its lovely”. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 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. Good complaints policies and procedures which are followed by the manager make sure that complaints are dealt with effectively. Residents are protected from abuse by good safeguarding training, effective recruitment and selection and detailed documentation. EVIDENCE: The complaints procedure is available in the service user’s guide and a copy is displayed in the home. The record of complaints made and investigated was looked at. The records are well managed. There is a complaint chart on the front of the records and this clearly shows the status of any complaints made. The records show that there was one complaint in January, two in February and there is one complaint that is currently under investigation. This is a low Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 16 number of complaints but shows the Managers willingness to address issues that are raised. She also can use the information as part of the quality assurance system. There is also a mechanism for analysing the complaints and a monthly report is sent to headquarters so that the company can monitor issues centrally. There has been one protection of vulnerable adult investigations in the last twelve months this was raised by the home. It was agreed that the home would carry out the investigation and take the necessary action or make the improvements. This has now been resolved and the manager has taken action to make sure that they have learned lessons from the issue both in improving the documentation and changing practice as necessary. Two of the residents who were interviewed during the visit understood how to make a complaint, and could identify the way this would be dealt with. The returned questionnaires confirmed that both relatives and residents are informed about the complaints procedure and all but one had not needed to use it. All staff working in the home are given protection of vulnerable adults training both as part of the in-house training package and from external trainers as available. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 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, 21, 24 & 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 home is clean, generally well decorated and well maintained and there is an ongoing programme to make sure that all of the areas are improved to the same standard. The staff are knowledgeable about how to reduce the risk of cross infection in the home. EVIDENCE: Swan Lodge is a purpose built care home situated on the same site as another care home owned by the same company. The home shares the kitchen and laundry services with the adjacent home. Swan Lodge is in a mainly Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 18 residential area close to local shops and well positioned for local transport and all local amenities. There is ample car parking to the front of the home. There are a range of specialist bathrooms, showers and toilet facilities throughout the home. One shower needs to have the flooring replaced and some re-decoration, however the manager is aware of this and there are plans to have the work carried out. The first floor is accessible by stairs and a passenger lift and the grounds are readily accessible. The communal rooms including the lounges and dining areas are clean and well decorated. There is a good selection of lounge chairs and a number of the residents were sitting comfortably watching television. The dining areas have been improved recently and are well decorated and set out to with condiments and a centrepiece. One dining room requires a new carpet and the manager has identified this as part of the re-decoration programme. Menus were displayed on the tables. The corridors have been recently redecorated and are very light and pleasant. All of the bedrooms are single and have en-suite facilities and they are personalised and organised in line with the wishes and choices of the resident. The Manager has plans to further improve the environment generally as part of the redecoration programme. The home is clean and odour free and there is liquid soap and disposable paper in the en-suites and appropriate waste bins are available so staff can dispose of the paper without leaving the room. Appropriately coloured aprons are available to allow staff to follow control of infection policies, and staff were seen to be using them correctly. Red dissolvable laundry bags are available and staff were therefore not handling soiled linen prior to it being washed. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): All of the standards were looked at. 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. There are sufficient numbers effectively recruited and well trained staff to make sure that the residents are well looked after. EVIDENCE: The staffing levels and skill mix is being maintained at levels agreed under the Registered Homes Act. This is on a sliding scale according to the number of residents accommodated and their dependency. At the time of the visit the staffing was, the Manager, Deputy Manager (both of whom are nurses) a Registered Nurse, five carers, two domestic staff and the administrator. The Regional Manager visited the home in the afternoon. Staff records were complete including application forms, two references and a completed interview form. The requirement to have a CRB and POVA check in place is applied to all of the staff in the home. Where necessary a work permit was in place. Health certificates/information were on in file and proof of Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 20 qualifications where necessary. Induction information is included in the records and quality assessments had been documented. The manager makes sure that the staff are up to date with moving and handling, first aid, and food handling and hygiene training. However the records for fire training suggest that some staff are not up to date with their fire training updates. The staff are offered a number of other training opportunities including pressure area care and continence training. The care staff are encouraged to undertake National Vocational Qualifications (NVQ 2). The NVQ training is commenced once staff have completed their induction training. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Resident’s personal allowances are managed effectively. The residents are protected through good health and safety practices and staff training. EVIDENCE: There has been a new manager appointed since the last inspection. She is not Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 22 yet registered with the Care Quality Commission although she has been registered with us for another home prior to her appointment. She has experience in both care of older people and management and has worked in care homes for 15 years. She has achieved her Registered Managers Award and has recently undertaken the End of Life palliative care training with Newcastle PCT. She has shown good leadership skills to make sure that the staff work well together as a team. She also makes sure that the home is run in the best interest of the people living there. The company has policies and procedures in place to ensure that the home is managed effectively and there are good reporting mechanisms to monitor the performance of the home. The regional manager visits the home and carries out a formal assessment at least monthly (Regulation 26) from which a report is written. The records of the arrangements to ensure that persons working at the care home receive suitable training in fire prevention and by means of fire drills and training in the procedures to be followed in the case of fire were examined and were adequate. The updates for all staff are up to date. There is a fire risk assessment in place which is up to date and detailed. There is a system in place to review health and safety in the home involving the staff, for which records are available. There were no obvious risks evident in the home, and the Manager confirmed that she undertakes daily tours herself to ensure that it remains so. Records were examined of the staff meetings, and the contents of these suggest that there is a broad spectrum of relevant issues discussed. These are posted in the staff room for those staff who were unable to attend. The Manager has had one to one meetings with the relatives and residents as appropriate. There have been monthly resident/relative meetings for which records are available; however these were not well attended. Newsletters are published three monthly and one is due now. The personal records kept in the home for residents who are receiving assistance to manage their finances were examined and are detailed, logical and appropriate. Receipts were in place for purchases made on behalf of residents and signatures of either two staff or one and the service user were in place. Supervision has been given to the staff in line with the national minimum standard and there is a matrix available to make sure that the Manager can prompt staff to keep up to date. They are generally on schedule to provide supervision six times per year. Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 3 18 3 3 X 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 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. 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. 1. 2. Refer to Standard OP8 OP15 Good Practice Recommendations All care records must be kept up to date and accurately show the care that is given. It is recommended that the way that the kitchen and care staff communicate be reviewed to ensure that the meal times are as positive an experience as possible for the residents. It is recommended that the remaining redecoration and refurbishment is undertaken as planned to make sure that the home is a pleasant place for people to live. 3. OP19 Swan Lodge DS0000028821.V376022.R01.S.doc Version 5.2 Page 25 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@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. 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. 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