Care Home: The Lodge Maldon

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What the care home does well The registered manager provides people with good up to date information which includes a range of publications by others, such as the local advocacy service, CSCI and the Department of Health. People get a thorough assessment of their needs before they move into the home. Care plans are well written and kept under review to ensure that any changing needs can be met. There are a range of activities available to people should they wish to participate in them. The Lodge offers people a comfortable, safe and welcoming environment which is nicely decorated and well maintained and people have their own personal belongings around them. People who use the service and their relatives are encouraged to share their views and opinions. The staff team are well trained and supervised. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 What has improved since the last inspection? This is the first inspection under the new ownership. What the care home could do better: The registered manager must make sure that the duty roster includes the full names of all of the staff that work in the home and the duty roster must show who has and who has not actually worked. Key inspection report CARE HOMES FOR OLDER PEOPLE The Lodge Maldon Lodge Road Maldon Essex CM9 6HW Lead Inspector Pauline Marshall Key Unannounced Inspection 7th July 2009 09:20 DS0000073189.V376482.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. The Lodge Maldon DS0000073189.V376482.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 The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Lodge Maldon Address Lodge Road Maldon Essex CM9 6HW 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) 01621 858286 01621 851062 Maldon Lodge Care Home Ltd Lisa Aitken Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Prospective service users of rooms 1,2 and 3 are informed by the registered provider that the eye level windows in these rooms open only onto the communal corridor serving these rooms, not onto any outside area/view. The total number of service users accommodated in the home must not exceed 20 persons. This is the first Inspection under the new ownership. 2. Date of last inspection Brief Description of the Service: The Lodge is a detached property set at the end of a private unmade lane. The north side of the home has views towards the River Black water. Maldon town centre is approximately half a mile away. The home has public transport close by; there is a bus route at the top of the lane. The Lodge has 12 single bedrooms and four shared bedrooms. Most have en-suite facilities. There are three communal lounge/dining rooms and adequate service facilities. There is a small enclosed garden at the front of the building and a well-maintained garden area, where people can sit to the side of the home. There is private car parking to the front of the building. The manager provides people with a copy of her Statement of Purpose and Service user’s Guide. The fees range between £425.00 - £550.00 per week depending on the type and style of room available and there are additional costs for toiletries, hairdressing, chiropody, newspapers and magazines and any private therapies. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. This was an unannounced key inspection that lasted for six hours and twenty minutes; it was the first inspection under the new ownership. All of the key standards were inspected; we checked a random sample of policies and procedures and examined some of the records that the home is required to keep. We looked around the building and we spoke to staff, some visiting relatives and the registered manager. The registered manager completed the annual quality assurance assessment (AQAA) and returned it to us within the required timescale; it was detailed and informative and provided us with good information about the service. The AQAA is a self assessment document that the manager is required by law to complete; we have used the information provided in the AQAA throughout this report. We sent surveys to the home to distribute to people using the service, health and social care professionals, GP’s and some of the homes staff to obtain their views on the service that the home provides. At the time of writing this report we had not received any completed surveys, however, we will ensure that any comments from surveys received after this report is written will be included in the home’s next report. What the service does well: The registered manager provides people with good up to date information which includes a range of publications by others, such as the local advocacy service, CSCI and the Department of Health. People get a thorough assessment of their needs before they move into the home. Care plans are well written and kept under review to ensure that any changing needs can be met. There are a range of activities available to people should they wish to participate in them. The Lodge offers people a comfortable, safe and welcoming environment which is nicely decorated and well maintained and people have their own personal belongings around them. People who use the service and their relatives are encouraged to share their views and opinions. The staff team are well trained and supervised. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 7 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 The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 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 receive good up to date information and they know that their needs will be fully assessed. EVIDENCE: The home’s Statement of Purpose and Service User Guide were recently updated to include the new contact details of the Commission; both documents were readily available in the reception area by the visitors’ book, together with copies of the last three inspection reports. The contact details of a local advocacy service were displayed on the notice board in the reception area, together with the contact details of the Alzheimer’s society. There was additional information displayed in this area, which included the CSCI In Focus report, CSCI newsletters, and the Department of Health’s guide on the Mental Capacity The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 9 Act 2005 Deprivation of Liberty Safeguards for family, friends and unpaid carers; there was a note on the rack inviting relatives to take copies. We looked at three care files and each of them contained a thorough pre-admission assessment that looked at all areas of need including daily routines such as waking and night time preferences, whether or not the person likes to rest during the day, what activities the person likes to do and it addressed all of their physical and health care needs. The manager said in her AQAA “all new residents are offered a trial period to suit their own personal circumstances”. People spoken with said they had visited the home prior to moving in and one relative said that the visits formed part of the admission process. The Lodge does not provide intermediate care. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of people using the service are fully met. EVIDENCE: We looked at three care files and each contained an up to date care plan that had been regularly reviewed; there was a photograph to identify the person, an information sheet and a residents’ profile that provided a clear picture of the individuals’ details, their likes and their preferences. The care plans that we looked at contained completed risk assessments for all areas of identified risks such as for falls and pressure area care; each of the risk assessments included plans on how the risks were to be managed and they had been regularly reviewed. The registered manager said in her AQAA “we put a detailed care plan in place within 24 hours of admission and they are regularly reviewed and any changes are discussed with the resident/family/advocate. People spoken with The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 11 including the relative of one of the people living in the home confirmed that they were involved in writing the care plan and that it is regularly reviewed. All of the care files that we looked at contained detailed information about peoples health care; there were records to show that health matters are regularly monitored such as weight and food/fluid charts where necessary. There were records to show that GP, hospital, dental, optical and chiropody appointments were attended and the outcomes and any follow up actions were recorded. People spoken with said “they look after me well and I get all the medical help that I need”. One relative said when spoken with “the home has always looked after my relatives’ health needs well and although the change of management was a bit unsettling, it is now fine again”. Daily care notes were recorded on the home’s computer using an E.C.S. (Elderly Care System) programme; they were detailed and informative and both the computer, and the individual notes were password protected. Staff was observed throughout the day interacting with the people living in the home and they were seen to be treating people with respect and in a dignified way. People spoken with said that staff always knock on the door and wait for their response before entering their rooms. Staff was observed on many occasions throughout the visit speaking with people living in the home on a one to one basis and there was laughter and friendly banter between them. The Lodge has an up to date medication policy and all of the staff that administers medication have had medication training and their competency has been regularly assessed. The staff supervision records showed that medication issues were discussed and that any medication training needs were identified; the training matrix confirmed that all senior staff had received an update in medication administration in the past six months. The home has recently changed its medication system and now uses the NOMAD cassette monitored dosage boxes; the pharmacist prepares the cassettes with a daily dose of each medication in separate compartments for the time of day. Staff spoken with said that although the system was new they felt that it was better, as it minimises the risk of errors. There was PRN protocols in place for all as and when prescribed medication and they described the circumstances in which the medication was to be administered. Staff spoken with was fully aware of the medication policy and the registered manager carries out regular audits. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 12 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. The Lodge offers people a choice of healthy meals and there is a range of appropriate activities available to meet their individual needs and preferences. EVIDENCE: The relative of one of the people living in the home said when spoken with that the home has “a friends of the Lodge” that consists of a group of relatives of both past and present residents and that they organises outings and activities. The Statement of Purpose lists some of the activities on offer, which includes art and craft, quizzes, board games, reminiscence, electric piano and video library. People living in the home said when spoken with that there are lots of activities and one person said “we get a good singer who sings the old songs for us and is really good, it makes me happy”. The registered manager said in her AQAA “we promote a ‘resident led’ environment and offer a selection of appropriate activities”. The activities records confirmed that regular The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 13 activities have been taking place and that they included an outside entertainer. The registered manager said that she has a mini bus on order and expects it to be delivered within the week and that it will provide people living in the home with more opportunities to access the local community. One person said when spoken with “I will be going to the garden centre to buy plants for my pots; the pots are in the garden outside my bedroom and the new minibus will allow me to do this as it will take the wheelchair”. Another person said when spoken with “I enjoy going to the shops and I can always find something to buy”. People spoken with said that regular meetings are held to discuss the home and how it is run; there were notes of the meetings that were held for people living in the home and there were also notes of meetings held for the relatives of people living in the home. Issues discussed at the meetings included, meals and mealtimes, activities, welcomes and goodbyes, the re-decorating programme, forthcoming events, staffing and staff training. People spoken with including visiting relatives said that they felt the meetings were productive and that although they found the new management style difficult at first, things were now improving. The Lodge operates a four week rolling menu that is subject to change when people living in the home require an alternative to the two options available on the menu. There were records to show any changes that had been made to the planned menus and the nutrition charts were completed to show the amount of food people had eaten. People spoken with said that they were “very happy with the food, it is good home-cooked food”, and “lovely meals, the staff always make sure that I get what I want”. In recent months the home has introduced a kitchen assistant to support the cook at lunchtimes and the registered manager said that this means that care staff no longer needs to assist in the kitchen. Staff spoken with said that this was a positive move and gave them more time to carry out their care duties. The Lodge had an environmental health visit on 13/05/2009 and achieved a 5 star excellent rating for their catering service. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 14 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 know that there complaints will be listened to and dealt with and that they will be protected from harm and abuse. EVIDENCE: There have been no complaints made since the new owners started trading but there is a complaints book available should any complaints be made in the future. The registered manager has reviewed the complaints procedure recently and it includes the new CQC contact details. The registered manager said that any minor concerns are dealt with immediately and staff spoken with confirmed this; one staff member said “we are generally able to resolve any problems as soon as we know about them”. The registered manager said in her AQAA “the home feels that constructive complaints are a good way to achieve a result of satisfaction”. The safeguarding policy was reviewed in January 2009 and works within the Local Authority guidelines. Staff spoken with showed a good knowledge of safeguarding procedures and the training records showed that all staff had attended training in abuse and whistle blowing. Eight of the homes staff have had training in the Mental Capacity Act The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 15 in the past month and one staff member said when spoken with how useful this information would be in their everyday work. There have been no safeguarding issues in the past six months. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 16 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. People live in a clean, homely and comfortable environment. EVIDENCE: The Lodge is a two hundred year old building and there are areas that require repair and refurbishment; the registered manager has an on-going programme for this. The lounge has been recently decorated and people spoken with said that it now looked much better. Each of the bedrooms we looked at were in reasonable decorative order and they contained many of the occupants personal belongings, including pictures, photographs, TV’s , radios and some small items of furniture. There was sufficient bathing and toilet facilities but there was limited space available for the storage of hoists and wheelchairs. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 17 The home manages this by using an area in one of the smaller lounges to store wheelchairs and although not ideal, there is still sufficient space for people to use the lounge. There was signage displayed throughout the home to help people with dementia to identify different areas of the home. There is separate accommodation beneath the building where the previous owner/manager of the service used to live, which is now used by one of the senior carers, his wife (who is a care assistant working in the home) and his son. The area is totally separate to the home and has its own entrance door. The registered manager said in her AQAA “there is a domestic team in place that have undertaken infection control training”. The communal areas were all clean, comfortable and homely and people spoken with said that the home was always kept clean and that the domestic staff was nice and friendly. The providers’ husband carries out any odd jobs or minor repairs to the home and these are recorded in the homes maintenance book; contractors are employed for any larger jobs. The records showed that repairs had been carried out in a timely manner. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 18 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. People are cared for by a competent and well-trained staff team, who are safely recruited. EVIDENCE: The duty roster showed the names of senior care and care staff only; domestic and catering staff was not shown on the duty roster and the shifts covered by agency staff were shown on the duty roster as agency. All staff working in the home, whatever their role must be shown on the homes duty roster. The duty roster showed that four staff works in the morning and three staff works in the afternoon and although not shown on the duty roster the registered manager said that domestic and catering staff is in addition to this. The Lodge has increased its night time staffing level and there are now two members of staffing working at night most nights. The registered manager said that occasionally it is not possible to fill a night shift; however, the senior carer that lives on site would be on call on these occasions. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 19 There was a cook, a kitchen assistant, teatime cook and a domestic working on the day of our visit. Staff spoken with said that they felt that the staffing levels were sufficient to meet people’s needs. One visiting relative said when spoken with “although several of the old staff has left, it is now feeling much more settled and the staff has always been kind, caring and helpful”. The registered manager said in her AQAA “all staff receives an induction programme on commencement of employment which meets minimum standards and 90 of staff hold an NVQ level 2 or 3”. The staff records that we looked at contained evidence of a full induction having taken place and there was copies of staffs NVQ certificates to confirm the registered managers’ statement. We looked at three staff files and we found that they all contained the required documents including a fully completed application form, two written references and a criminal records bureau (CRB) check. Eight staff have left the home since the new management took over in January 2009 and a further eight staff have started work at the home since then. The registered manager said that there are vacancies for one full time and one part time carer and that she has advertised in the local press and the local job centre. Staff spoken with said that the recruitment process was thorough and the records of recently employed staff confirmed this. The registered manager keeps an agency profile for each of the agency staff that had recently worked in the home; this profile provided confirmation that all employment checks had been carried out and showed the level of training the worker has undertaken. Staff spoken with said that the home offers them good training opportunities and that they have regular staff meetings where training is often discussed. We looked at three staff files and there was evidence of staff training in moving and handling, first aid, food hygiene, fire awareness, health and safety, challenging behaviour, Mental Capacity Act, Safeguarding, dementia, medication and bowel and catheter care. The training matrix showed that most of this training had taken place in the last six months. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 20 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. People live in a well run home that is run in their best interests and they are cared for by a well supervised staff team. EVIDENCE: The registered manager is also part owner of the home and has many years experience in the caring field and holds an NVQ 3 in Care qualification in addition to the registered managers’ award. The registered manager regularly updates her practice and has The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 21 recently undertaken training in safeguarding, manual handling, dementia awareness, food hygiene, palliative care, challenging behaviour, conflict resolution and person centred dementia. The registered manager said that she has recently appointed a deputy manager to assist in the management role at The Lodge. The deputy manager has worked at the home for more than ten years and said that she is looking forward to the challenge of her new role and is happy to be part of the management team. The registered manager sent her own questionnaires to people living in the home and their relatives to establish whether the service is of the expected quality. There was a good response from people, and where particular issues have been raised, the registered manager has offered to meet with individuals to discuss and resolve any concerns or worries. The registered manager said that she intends to analyse the information and formulate a report, which will be made available to all interested parties. Regular meetings were held for the people living in the home and their relatives and detailed notes of these were available for people to read. The registered manager returned her completed annual quality assurance assessment (AQAA) by the due date and it contained all of the information that we had asked for. The provider carries out regular visits under regulation 26 and reports are made and kept on file in the home. We examined a random sample of the cash and cash transaction records belonging to people living in the home and we found them to be accurate and up to date. We looked at three staff files and they contained evidence that supervision has taken place on a regular basis and the content included an evaluation of staff practice and knowledge in addition to identifying any training needs. The supervision document also looked at team building issues, management issues and personal issues. Staff spoken with said that their supervision sessions were positive and that they felt well supported. We looked a random sample of safety certificates and all were in place and up to date. The home makes regular weekly checks on the fire doors, fire alarms, and emergency lighting; the records were fully completed to confirm this. The records showed that regular fire drills are held and the last one took place on 24/03/09. The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 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 3 X 3 The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? First Inspection under new ownership 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 OP27 Regulation 18 Requirement The registered manager must ensure that the duty roster shows staffs full names and whether or not they actually worked. Timescale for action 28/08/09 To ensure that the duty roster shows which staff has worked in the home. 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 The Lodge Maldon DS0000073189.V376482.R01.S.doc Version 5.2 Page 24 Care Quality Commission 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. 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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