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Inspection on 08/09/08 for Erskine Hall Care Centre

Also see our care home review for Erskine Hall Care Centre for more information

This is the latest available inspection report for this service, carried out on 8th September 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

"I have been very happy here" was the comment of one long-term resident and as was the case at the previous inspection there was generally a high level of satisfaction expressed by people living in the home about the standard of care they receive. Staff, people living in the home and their relatives were generally positive about the new management team and the effect they were having on the home, working with some of the more established staff. Staff in particular said that they received good training and support. "I have a very good workingrelationship with my manager and thoroughly enjoy my job" was the comment of one member of the staff team. Particularly positive comments were received during the inspection about the activities and the activities organiser; "He is the life and soul of the home" and "He really makes a difference to the people living in the home" were some of the tributes paid.

What has improved since the last inspection?

The requirements made following the previous inspection in September 2007 have been addressed. The manager has successfully registered with the CSCI having been assessed to be a fit person to manage a care service. The new manager came into post in January 2008 and has, together with her staff team and people living in the home taken time to identify areas where improvements can be made, including extended activities provision to include weekends, meals and laundry service and medication practice. Some improvement in these areas can already be seen with further changes planned over the coming months. One relative noted that the manager was "Trying very hard to improve things". Additional care staffing has been put in place and this was acknowledged as an improvement by people who responded to the CSCI in surveys, as it provides people living in the home with improved support at key times of the day, for example in the morning (but please also see below). The progress made in the operation of the home since the last inspection has been recognised in the improved overall rating given.

CARE HOMES FOR OLDER PEOPLE Erskine Hall Care Centre Watford Road Northwood Middlesex HA6 3PA Lead Inspector Jeffrey Orange Unannounced Inspection 8th September 2008 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Erskine Hall Care Centre Address Watford Road Northwood Middlesex HA6 3PA 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) 01923 842 702 01923 842 703 erskinehallall@bupa.com www.bupa.com BUPA Care Homes (AKW) Ltd Mary Hagon Care Home 85 Category(ies) of Old age, not falling within any other category registration, with number (85), Terminally ill over 65 years of age (10) of places Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This home may accommodate one person aged 50 years or over who requires nursing care. To admit (within the current registration limit of TI category) three terminally ill persons between the age of 18 to 65 years. 24th September 2007 Date of last inspection Brief Description of the Service: Erskine Hall Care Centre is part of BUPA Care Homes Limited and is registered to provide nursing care and accommodation for up to 85 older people. Within that number the home is registered to provide terminal care for up to 10 persons, of whom up to 3 may be between the ages of 18-65 yrs of age. Erskine Hall is a purpose built nursing home, set back from the road in extensive grounds, with good parking facilities. Accommodation is arranged on three floors, each with a day room and served by a passenger lift. All rooms exceed the minimum size required by the National Minimum Standards and have en-suite facilities. Catering and laundry facilities for the home are situated in the basement along with a hairdressing room. Erskine Hall is situated in Northwood, Middlesex, conveniently situated for North West London and South West Hertfordshire, with good access to public transport. The home’s Statement of Purpose, Service User Guide and previous CSCI inspection reports are available in the home. The current fee range for this service is £513 to £1,039 per week (confirmed at 08/09/08). BUPA’s terms and conditions of residence clearly set out what is included in the weekly fee and what is available at additional charge, for example hairdressing, private healthcare treatments, escort duties and personal purchases such as newspapers and toiletries. Erskine Hall Care Centre DS0000019345.V370849.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 the people who use this service experience good quality outcomes. This was a key unannounced inspection and took place over approximately 7 hours starting during the early morning routine of the home and continuing through until the afternoon. During this inspection visit we were able to observe the care experience of people living in Erskine Hall and to talk to them about it, we were able to speak to relatives of people living in Erskine Hall and listen to any concerns or comments that they had. We discussed future plans for the home with the manager and spoke to members of the staff team. We were also able to look at some key records, including those for staff recruitment, supervision and training, care planning and medication. This report also draws on information provided from surveys of people living in the home and staff as well as information received from the home in their Annual Quality Assurance Assessment (AQAA) submitted to the Commission for Social Care Commission (CSCI). The AQAA is a self-assessment and dataset that is completed once a year by all care providers and which gives details of how they assess they are meeting the care needs of people living in Erskine Hall as well as providing some useful statistical information about the home. This report also takes account of any information received by the CSCI about Erskine Hall since the last inspection in September 2007, including any arising from meetings held under the joint agency safeguarding procedures of Hertfordshire County Council Adult Care Services. What the service does well: “I have been very happy here” was the comment of one long-term resident and as was the case at the previous inspection there was generally a high level of satisfaction expressed by people living in the home about the standard of care they receive. Staff, people living in the home and their relatives were generally positive about the new management team and the effect they were having on the home, working with some of the more established staff. Staff in particular said that they received good training and support. “I have a very good working Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 6 relationship with my manager and thoroughly enjoy my job” was the comment of one member of the staff team. Particularly positive comments were received during the inspection about the activities and the activities organiser; “He is the life and soul of the home” and “He really makes a difference to the people living in the home” were some of the tributes paid. What has improved since the last inspection? What they could do better: An immediate requirement was made on the day of the inspection in respect of some uneven carpet that could pose a health and safety risk to people living in, visiting or working at the home. Whilst this had been identified by the manager as a risk, she had not been supported and enabled to address it in a sufficiently timely fashion. The manager has confirmed that this is now being addressed and a sign to warn people of the possible trip hazard is now in place. The delay in implementing the major refurbishment of the home means that some areas are now looking rather tired and in need of attention in order to continue to provide people living in the home with a pleasant and safe environment. Some responses to surveys, including from members of staff, identified staff shortages as an issue at times, despite the increase in staffing that has already been achieved. Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 7 It is acknowledged that the home’s AQAA identifies all of the areas requiring attention which came to light during this current inspection and this should provide confidence to people living in the home that the manager is carrying out a robust and realistic quality assurance process. It is important that where improvements are identified as necessary, that they are given appropriate priority and resources to address them within a satisfactory timescale. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Erskine Hall Care Centre DS0000019345.V370849.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 Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 (Standard 6 does not apply to Erskine Hall) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are considering Erskine Hall as a home for themselves or someone they are responsible for can be confident that there is a thorough and robust pre-admission assessment process in place to ensure that only those people whose care needs can be fully met are admitted to the home. The range and quality of information about the home that is available to people thinking about Erskine Hall as a potential home for themselves or someone they are responsible for, including terms and conditions with full details about fees and what is and isn’t included in them, should mean that they can make a well-informed decision. Pre-admission visits either by the person themselves or those responsible for them are encouraged and facilitated and this should enable them to decide if they will be happy there and that the home can provide them with what they want and need. Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 10 EVIDENCE: When we asked people “Did you receive enough information about this home before you moved in so you could decide if it was the right place for you? They all answered in the affirmative. One person noted “Very rapid decision of necessity, but BUPA very helpful”. During our inspection visit we were able to observe a person who was asking about possible admission of a relative being provided with a range of information and advice, including very clear discussion about fee levels. They were then given a tour of the premises by a member of the home’s administrative team. When we looked at the pre-admission assessments undertaken for some of the people who have recently been admitted into Erskine Hall, we found that they were very detailed and thorough and were able to identify individuals’ needs and how they were to be met. Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those people who live in Erskine Hall and rely on staff to assist and support them with their medication can be assured that the home has effective medication policy, procedure and practice guidelines which are routinely monitored to ensure that they are carried out in a way that protects them and maintains their health and safety. People receiving care in Erskine Hall can be confident that their personal, social and healthcare needs are clearly recorded in a personal care plan that provides the basis for the delivery and review of their care and that the care plan process will involve them and be kept up to date, with changes in their needs being identified and the care plan changed if necessary so that they can be met. Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 12 EVIDENCE: When we asked people living in Erskine Hall “Do you receive the care and support you need?” 98 responded that they always did, with 2 indicating that they usually did. When we looked at care plans for some of the people we had spoken to or who had been recently admitted, we found that they were clear, informative and well completed. This should provide care staff with the information they need in order to determine what care is required and when and how it should be given. Looking at details in the care plans about GP and other healthcare professional involvement, it was clear that people living in Erskine Hall have access to a range of healthcare services from the community as well as in the home. Again 98 of people asked said that they always received the medical support they need. When we spoke to relatives about the care received by the people living in the home they are responsible for, even when there were reservations about some aspects, they were in general positive about the majority of care staff and the standard of care given. When we checked medication records on each floor during this inspection visit, we found that the standard had improved since our last inspection in September 2007, although there were still some minor areas where for example, variable dosages of medication had not been fully detailed at the time they were given. However, overall people are well protected by the way that medication is administered and monitored. Erskine Hall Care Centre DS0000019345.V370849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in Erskine Hall can be assured that they will be supported and encouraged to enjoy a stimulating lifestyle with a variety of options to choose from. Routines, activities and plans are person centred and flexible and are reviewed regularly so that people living in Erskine Hall can be reassured that if their needs or preferences change, this will be reflected in practice. People living in Erskine Hall can be assured that they can have meals at flexible times and in a variety of locations according to their wishes each day. EVIDENCE: When we spoke to people living in Erskine Hall they told us that there were activities for them to choose from “most days if not every day”. The activity organiser was said by one relative to “make a difference” to the quality of life for people who live in the home. Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 14 Care plans that we saw included activities records and details of the individual interests and concerns of people living in the home and how these were to be reflected in their care. The home’s AQAA also identifies the need to develop more activities in the evening and weekends to spread the time that specific activities are available for people to take part in if they choose to do so. When we spoke to the manager she told us that she was hoping to appoint an additional activity organiser who would be able to help provide activities at week-ends so that those people who rely on the home to provide them with activities will have that opportunity seven days of the week. When we asked people about meals and food they told us “There is always a wide choice” and “A good selection – sometimes presentation could be more appealing”. People who responded to our surveys noted that they either ‘usually’ or ‘always’ liked the meals at the home. The AQAA gave details of how menus are drawn up and how people living in the home can and do influence the choices of food through regular resident’s meetings and specific meetings and conversations with the chef manager. When we observed meal times in the home, we saw care staff offering assistance to those that needed it in a polite, non intrusive way, that respected their dignity. The chef manager confirmed that the home had access to the CSCI report “Highlight of the day” which is about ways that the mealtime experience for people in care homes can be improved and enhanced. It is understood from conversations with the manager that this will be used to help inform the evaluation of the mealtime experience for people living in Erskine Hall that takes place on a regular basis and which process includes people living in the home. On the day we visited the home we were able to see staff engage on a one to one basis with people living in the home. Erskine Hall Care Centre DS0000019345.V370849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in Erskine Hall and those who are responsible for them can be confident that the home provides a safe and understanding environment in which they can freely express their views and any concerns they may have, without repercussions for themselves or those they are responsible for. People living in Erskine Hall can be assured that staff working in the home are supported through training to be able to recognise actual or potential abuse and to know what action to take if it is seen or suspected and this should safeguard the well being of people living in the home. EVIDENCE: When we looked at staff training records we found that they included safeguarding (adult protection) training and that the Hertfordshire County Council Adult Care Services joint agency safeguarding procedure is available in the home for staff to follow in the event that a safeguarding referral has to be made. Since the last inspection the home have been involved in safeguarding meetings called under the safeguarding adults from abuse procedure of Hertfordshire County Council’s Adult Care Services. They have co-operated Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 16 fully in that process and have demonstrated a willingness to learn from events and to put in place additional safeguards where that is appropriate. This should provide confidence for people living in Erskine Hall and for those who care for them that the home treats the protection and well-being of people living in the home seriously and as a priority. When we have talked to staff they have shown that they have a good understanding of what constitutes abuse and also they recognised the term ‘whistle blowing’ which suggests that they would feel able to raise any concerns outside of the home if they felt they needed to. This level of awareness provides confidence that the people who live in the home are not at risk from staff not knowing how to recognise abuse or what to do if it is seen or suspected. The home has a complaints policy and procedure that is clear and accessible and which should provide people with confidence that any complaint they make will be listened to and taken seriously. When we spoke to one relative of someone living in the home, they indicated that their relative didn’t want to ‘make a fuss’ in case ‘they got into trouble’. There is no suggestion that this would be the case, but this reluctance to complain is not unusual within care settings. The relative concerned did indicate that they felt able to deal directly with the manager and this was seen to be the case during this inspection. When we asked people who live in the home if they knew who to speak to if they were not happy and if they knew how to make a complaint, they all indicated that they were and one noted “The manager is very approachable”. Erskine Hall Care Centre DS0000019345.V370849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst Erskine Hall offers a pleasant, comfortable and generally safe environment for the people who live, work or visit there, there are some areas of the home that require refurbishment and some specific risks to health and safety which, whilst identified and acknowledged have not been addressed in a timely way and this poses a risk to people living and working in the home EVIDENCE: We left an immediate requirement in respect of a badly uneven carpet in one part of the ground floor corridor as we felt that this represented a potential and actual risk to the safety of people using that corridor. The manager has confirmed that a sign to warn people of the possible trip hazard is now in place. Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 18 When we spoke to the manager about the carpet she indicated that her efforts to have this addressed had not been successful up to that point. We were told by one relative; “Carpet on part of ground floor corridor ‘ruckedup’ to the extent of being dangerous…mentioned to management repeatedly over several months…getting worse” We were told that the reason given for lack of remedial action was that a major refurbishment of the home, to include floor coverings was to start in July. The home’s AQAA told us that “The home is to undergo an extensive refurbishment commencing in July 2008” At the time of the inspection visit (8th September 2008) the refurbishment had not started. When we walked round the home on the day of the inspection we found that the home was clean and free from unpleasant odours. When we asked people “Is the home fresh and clean?” 50 said it always was and 50 said it usually was. Erskine Hall Care Centre DS0000019345.V370849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in Erskine Hall can be confident that the care they require will be provided by well trained and supported staff, in the numbers necessary to achieve good care outcomes for them and who have been subject to a robust recruitment process to ensure that they are fit to do so. EVIDENCE: When we spoke to members of the staff team they told us about the training they had received, including at level 2 and 3 NVQ in care. This, together with records of training given and due in future, demonstrates that staff have the skills they need to provide care to the people who currently live in Erskine Hall. One person we asked noted that since the number of carers had been increased in the morning “things were much better”. Of the responses received from people living in the home and from staff, 50 expressed some concern about the numbers of staff on duty on some occasions. “Carers can be thin on the ground sometimes” ,“The staff work very hard, the home needs more staff” were comments by people living in the home and “The home should employ more care assistants to cover the occasional Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 20 staff shortage” and “there are now more people who need two carers to help them” were some comments by members of the staff team. When we talked to the manager she confirmed that staffing levels are always kept under review and are determined taking into account the dependency levels of people living in the home. When we looked at schedules for supervision and talked to care staff we were able to confirm that staff are supervised regularly and that on an annual basis, formal supervision will meet the frequency required. This should give people living in the home confidence that they are receiving care from staff who are well supported and are given the skills they need to do so appropriately. Staff spoken to and surveyed indicated that they felt very well supported by the manager and her team and that they felt able to approach them with any requests for additional training. When we looked at recruitment records we found that they included evidence of the checks needed to protect people living in the home from receiving care from staff who may not be suitable or safe to do so. Erskine Hall Care Centre DS0000019345.V370849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Erskine Hall can be confident that they live in a well managed home where their wellbeing and best interests are given priority in decisions made. However, the corporate decision making process can sometimes lead to delays in dealing with maintenance and health and safety issues promptly. Staff working in the home can be confident that they will be well supervised and supported to help them meet the care needs of people living in the home. People living in the home can be assured that it has an effective system to continually assess the quality of service being provided to them. People living in the home are protected by the system in place to record and audit financial transactions carried out on their behalf. Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager, who took up post in January 2008, has been registered with the CSCI as a fit person to manage a care home. People living in the home, relatives and members of the staff team all told us that they felt the manager was approachable and that she and her team had achieved progress over the past few months. “She tries very hard” and “she has done well” were some comments recorded. When we spoke to people who had concerns about how their relative’s care was being provided, they assured us that they felt able to raise these with the manager and throughout this inspection we saw that this was the case. Complaints are recorded although we found greater emphasis is placed on dealing with the issues raised as they arise. When we looked at details of resident’s meetings, consultations and other interactions with people living in the home and those responsible for them, we found that communication with them is given a high priority by the home in order to ensure that improved outcomes for people living in the home are kept at the forefront of decision making. We found that this was explicit throughout information provided to us by the home in the AQAA. Delays in responding to a specific issue with health and safety implications, detailed elsewhere in this report suggest that it is possible for organisational pressures and processes to delay timely decisions and action to rectify concerns. Previously when we have looked at the system of recording and audit used by BUPA in respect of monies held by the home on behalf of people living there, we have found that it is rigorous and provides confidence that people living in the home are well protected from financial abuse or mismanagement. Erskine Hall Care Centre DS0000019345.V370849.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 3 X 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 2 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 3 3 X 3 X X 2 Erskine Hall Care Centre DS0000019345.V370849.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. 1 Standard OP19 Regulation 13(4c) Requirement Timescale for action To ensure the safety of people using the ground floor corridor, where the carpet is badly ‘rucked up’ and uneven it must be 22/09/08 removed, repaired or replaced and until that is done warning signs must be provided to alert people using the corridor to the potential hazard. Confirmation that the sign is in place to warn people of the trip hazard has been received since the inspection. 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 Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Erskine Hall Care Centre DS0000019345.V370849.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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