Inspection on 12/03/08 for Elwick Grange

This inspection was carried out on 12th March 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.

Other inspections for this house

Elwick Grange 06/07/10

Elwick Grange 05/05/10

Elwick Grange 18/11/09

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Elwick Grange Elwick Road Hartlepool TS26 9LX Lead Inspector Jean Pegg Unannounced Inspection 10:00 12 March 2008 th 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 Elwick Grange DS0000070551.V356881.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. Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elwick Grange Address Elwick Road Hartlepool TS26 9LX 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 487 7864 0191 487 7865 Southern Cross OPCO Ltd Care Home 60 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (44) of places Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category - Code OP, maximum number of places 44 Dementia, over 65 years of age - Code DE(E) maximum number of places 16 The maximum number of service users who can be accommodated is: 60 New Service. First inspection visit. 2. Date of last inspection Brief Description of the Service: Elwick Grange is a purpose built residential care home that provides accommodation for 60 people. All 60 bedrooms are spacious and have en-suite facilities. People living at the home have access to 8 communal lounge areas and 3 dining rooms. A passenger lift is available for people to access the first floor. Outside the home there are a number of car parking spaces and the home is surrounded by well kept flower beds, garden and patio areas. The home is located near to the centre of Hartlepool and is easily accessible to people using cars or public transport. There are a number of shops nearby and a well-kept public park area is opposite the home. At the time of this inspection visit the fees for living at this home were: General residential care £423 per week. Dementia care £432 per week. There are additional charges for items such as hairdressing, clothing, reading materials, toiletries and other personal items. Please check current fees and additional charges with the manager. Elwick Grange DS0000070551.V356881.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 star. This means the people who use this service experience good quality outcomes This inspection took place on Wednesday 12 March and lasted for 71/2 hours. The information used to write this report was gained from a variety of different sources including the results of surveys sent to the people who live and work at the home and their relatives. We received surveys from 9 relatives, 7 staff and 16 people who live at the home. We also visited the home and talked to people, observed what as going on during the day, looked at care plans and other important documents and records held in the home. The manager who helped us with the inspection had only recently been appointed to manage the home. She was able to tell us about her plans for the home. What the service does well: People have access to information about the home that describes the type of care it provides. People living at the home have their needs assessed before they are admitted into the home. Contracts that specify the terms and conditions of residency are provided to people living at the home. Individual care plans are in place for the people living at the home. These care plans describe how their needs will be met and state what preferences they have for different things. One person told us “There is always someone available to deal with my needs whatever they might be.” Health needs are met by visiting health professionals such as GPs, nurses, chiropodists and opticians. A relative told us “they keep relatives well informed and in the loop regarding all aspects of care, medical problems and diet.” Peoples’ medicines are looked after properly and individual privacy and dignity is respected. The staff in the home handle issues concerning death and dying in a sensitive way. Social and recreational activities in the home are currently limited due to the absence of the activities coordinator. The manager has plans in place to improve this situation. One person told us “just enjoyed a valentines evening with entertainment.” People are encouraged to have contact with the wider community, family and friends. People can exercise choice and control over their lives. Meals and meal times are managed well in the home. “Meals are good on the whole” People who have contact with the home know how make complaints about the home. The people living at the home are protected through the home providing Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 6 training and information about what abuse is and how to make adult protection referrals. The home is furnished and decorated to a good standard. It is well maintained inside and out and is clean and homely. Generally the home has enough staff on duty to meet the needs and dependency level of people who live at the home. Staff are trained to do their jobs and the home carries out proper recruitment checks. The home has an experienced manager who is qualified to run the home. Quality assurance systems are in place to make sure that things are running smoothly and are being done properly. Any money held on behalf of people living at the home is accounted for. Health and safety issues are addressed by the homes systems and procedures for maintenance. What has improved since the last inspection? What they could do better: 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. Elwick Grange DS0000070551.V356881.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 Elwick Grange DS0000070551.V356881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5. People who use the service experience good quality outcomes in this area. There is information available about the home and what it provides for people. People living at the home have their needs assessed before they are admitted into the home. Contracts that specify the terms and conditions of residency are provided to people living at the home. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide have been updated to show the correct details of the manager and the responsible individual. Information about the home can also be made available in cassette form if needed. In our survey we asked relatives “Do you have information about the care home to help you make decisions? 4 said “Always” and 5 said “Usually.” One relative added “An induction leaflet for relatives would have been useful e.g. about the Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 9 need to label clothing, not to bring in wool garments etc. several items ruined in wash. Procedures needed explaining.” We also asked the people living in the home “Did you receive enough information about this home before you moved in so you could decide if it was right for you?” 13 said, “Yes” and 2 said “No”. The comments that were added included ““Came on a visit to see it.” And “Daughter came to talk to manager.” We looked at care plans and spoke to staff about who was responsible for assessing individual care needs before someone is admitted to the care home. We were told that the manager or other senior staff are responsible for the assessment and that these are kept on file. We also saw copies of the single assessment documents used by the local authority who place people in the home. The manager told us that the new contracts with Southern Cross that identify the terms and conditions of residency are being sent out for families to sign and return. We asked people if they had received a contract 9 said “Yes” and 4 said “No”. Elwick Grange DS0000070551.V356881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. People who use the service experience good quality outcomes in this area. Individual care plans are in place for people living at the home and their health needs are met. Medication is managed appropriately and privacy and dignity is maintained. Issues concerning death and dying are approached in a supportive and sensitive manner. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager explained that senior staff had only just received training in how to write care plans in the corporate format adopted by Southern Cross homes. The manager was also aware that some care plans were not up to date with the recommended standard of monthly evaluations. We were reassured that plans were in place to bring all care plans up to date as soon as possible. The 5 care plans that we looked at included those written for people who were living in the general residential and dementia care units. The care pans seen contained lots if information including assessments for daily living, bed rail Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 11 assessments, records of bathing frequency and temperatures etc. The care plans were quite detailed in how care should be provided for each person. We were concerned that the files where the plans were kept could not be locked. The manager said that this would be dealt with straight away. We asked the people who live at the home if they thought that their care needs were met. These are some of the things they told us “There is always someone available to deal with my needs whatever they might be.” And “The care I receive from Elwick is second to none.” The care plans and daily records showed evidence of other health professionals visiting for example GP visits, district nurses calling to attend to dressings etc. optician and chiropody visits. People living at the home told us “Staff keep an eye on me and anything I need regarding medical support is addressed.” And “I was taken to hospital when I fell. Staff say they will call for my doctor if I need him” One relative also told us “they keep relatives well informed and in the loop regarding all aspects of care, medical problems and diet.” We observed one of the senior care staff administering medication. The home adopts a system whereby the person in charge of the medication round wears a special tabard instructing people not to interrupt them whilst they are giving out medication. This helps to prevent the person in charge of medicines from being distracted from the task they are completing. The home uses a monitored dosage system whereby the pharmacy pre packs individual medicines ready to give out. The manager and the deputy complete medication audits to make sure that procedures are followed correctly. The people we spoke to did not raise any negative comments about the care they received or the way that staff treated them. The rooms that we were invited into had evidence of people bringing their own possessions. One lady told us about the history behind certain items in her room. Keys for bedroom doors are given out when a person is admitted if they want one. We noticed on the care plans that they indicated whether or not the person preferred a male or female member of staff to assist them with personal care such as bathing. During our visit we became aware of some special arrangements that had been out into place to enable someone living at the home who was unable to attend a family funeral to have a special moment of prayer in the privacy of their own room. This event had been organised by a member of staff in the home. Elwick Grange DS0000070551.V356881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. Activities are currently limited in the home with plans to improve. Contact with the wider community, family and friends is encouraged. People can exercise choice and control over their lives. Meals and meal times are managed well. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: We were told that the activities coordinator was off sick and had been so for some time. The manager told us that it was planned that a member of staff was going to provide 20 hours activity support to cover the absence. During our visit we noticed that a painting session was in progress upstairs and that quite a few people were taking part. There were also lots of notices advertising future events that were planned to take place. In our survey we asked the people living at the home “Are there activities arranged by the home that you can take part in?” 2 said “Always” 7 said “Usually” and 5 said “Sometimes.” These are some of the things they told us that they did “carpet bowls, concerts, dominoes.” And “just enjoyed a valentines evening with Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 13 entertainment.” We were also told “Our regular organiser is currently on sick leave” and “Not enough to do. The home has been without a social organiser for over three months. Something regular to look forward to used to be great e.g. pamper sessions. The biggest complaint I hear in general is boredom factor.” One relative agreed by saying “My mother is on the whole very happy and settled here. The only request is would like more to do through the day such as local trips and more musical interlude. As mother is alert but unable to walk.” During our visit we noticed that there were lots of visitors coming and going. In one of the homes’ information leaflets there is a section explaining about visitng the home and taking meals with relatives. The care plans that we looked at showed evidence of individual preferences and choices being recorded. The care plans also reinforce that people have a right to choose and refuse. On the dementia care unit we noticed that one bedroom had been locked and asked that when this happens the reason for locking the room is recorded in the persons care plan. The manager agreed and said that this would be done. On the day that we visited the lunch being served was a choice of corned beef pie and chips or chicken curry and rice with fruit trifle for dessert. Background music was being played in the dining room. We spoke to the cook who explained that the home would soon be moving to the ‘nutmeg’ system which was being introduced by Southern Cross. This system ensures that all meals offered have good nutritional values. We asked people “Do you like the meals at the home? “ 5 said “Always” 9 said “usually” and 1 said “ sometimes.” Additional comments included “very good” “Meals are good on the whole” and “No complaints at all.” Elwick Grange DS0000070551.V356881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. People know how make complaints and people are protected through the home providing training and information about how to make adult protection referrals. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager said that the complaints procedure would be updated to show her new contact details. The complaints book was seen. The record showed a clear record of complaints made and the actions taken to resolve the complaints. We were also shown the untoward incident book. We asked the people who live at the home “Do you know who to speak to if you are not happy? 12 said “Always” and 4 said “Usually.” They told us ““Yes people are always available. I’ve been told just to ask for anything I need.” “The senior staff are always available” and “I would speak to manager” We also asked “Do you know how to make a complaint?” all 16 respondents said “ Yes” One said “Just ask, but I haven’t any complaints. X will help if I have.” Staff and relatives also indicated that they knew what to do if they had concerns or wanted to make a complaint. We asked relatives “Has the care service responded appropriately if you or the person using the service has raised concerns about their care?” 7 said “Always” and 2 said “Usually.” Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 15 We were told that the staff were provided with ‘No secrets Tees Wide Training.’ We saw that the appropriate contact numbers fro raising alerts were easily available for staff to use. The manager also told us that they had a good level of contact with the local Community Psychiatric Nurses who will do staff training around dementia and challenging behaviour. In the past the Alzheimer’s Society training was also offered to relatives. We know from past records that the home knows how to make appropriate adult protection referrals. Elwick Grange DS0000070551.V356881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. The home is furnished and decorated to a good standard. It is well maintained inside and out and is clean and homely. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: We walked around the building both upstairs and downstairs. The home was nicely decorated and furnished. The manager told us about improvements that she would like to make to the dementia care unit to improve the environment. These proposed improvements would be seen as good practice in the care of dementia people. There were no unpleasant odours evident during our visit. In our survey we asked the people living at the home “Is the home clean and fresh? 15 said “Always” and 1 said “Usually.” They added “All very clean and Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 17 looks nice” “Very pleasant surroundings. Spotless.” And “the home is always clean and fresh with a happy atmosphere. The staff are cheerful and this reflects on the residents. The home has modern laundry facilities and we were told that the equipment is all in good working order. The staff working in the laundry have completed appropriate training for the job. All of the cleaning trolleys that we saw being used had products that were correctly labelled for health and safety reasons. Elwick Grange DS0000070551.V356881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. Generally the home has satisfactory staffing levels to meet the needs of the current number of people and dependency level who are living at the home. The home provides staff with relevant training and proper recruitment practices are followed. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: We looked at the staffing numbers for each unit and floor and observed how those hours were being used. We found out that there were five staff upstairs who worked across two units that accommodate 30 people including up to 16 people with dementia. Downstairs in the general residential unit there were 3 staff for up to thirty people. The staff on duty did not appear to be rushed when completing tasks. Staff were seen spending time talking to people living at the home and we did not notice any unnecessary rushing around. The home also accommodates students on work experience and trainee schemes. The manager told us that there had been problem with staffing levels but that recruitment had now started to help ease those problems. We asked the people living at the home “Are the staff available when you need them?” 10 said “Always” and 6 said “Usually.” We also asked staff “Are there enough staff Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 19 to meet the individual needs of all the people who use the service?” 3 said “Always” 1 said “usually” 3 said “sometimes” and 1 said “never.” These are some of the comments made “ we were nearly always short staffed from Christmas onwards but more fully staffed in last few weeks. We had to use cleaners and laundry and kitchen staff as carers to cover sometimes or agency.” Relatives told us “the care home has been experiencing staffing problems due to carers leaving and long-term sickness. However, I understand things will improve over the coming weeks.” We were told that 37/38 staff has a National Vocational Qualification in Care at level 2 or above. We audited some staff recruitment files and found that all the checks that we would expect to be carried out had been. In our survey we asked staff “Did your employer carry out checks such as your CRB and references before you started work?” 8 said “Yes.” We asked staff “Did your induction cover everything you needed to know to do the job when you started?” 6 said “Very well” 1 said “mostly” and 1 said “partly.” Comments that were added included “My induction was done very well told everything I needed to know.” We also asked “Are you being given training that is relevant to your role, Helps you meet individual needs and Keeps you up to date with new ways of working?” 7 people said “yes”. We also asked relatives “Do the care staff have the right skills and experience to look after people properly?” 9 said “Always” We looked at training records and noticed that staff had received a lot of different training. We were told that the home has to submit a training plan to the Southern Cross training department so that training can be organised. Elwick Grange DS0000070551.V356881.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People who use the service experience good quality outcomes in this area. The home has an experienced manager who is qualified to run the home. Quality assurance systems are in place and money held on behalf of people living at the home is accounted for. Staff supervision needs to improve. Health and safety issues are addressed by the home. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager has only recently taken up the post at Elwick Grange. She has 10 years management experience gained in other care homes and she has the Registered Managers Award and National Vocational Qualification in Care at Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 21 level 4. The manager told us that she has completed her planned induction with Southern Cross and has been allocated a mentor to help her settle in to her role. The operational manager visits each month and completes a monthly report. This report is a requirement under regulation 26 of the Care Home Regulations. The manager and operations manager also complete a quality audit and compare results. The manager told us that she needs to develop some new service user/ stakeholder surveys to find out what people think about the service and what improvements they think can be made. The manager has already implemented an action plan that has led to improvements in the management of medication. We were also shown some different audits that had been completed in the home by the deputy manager. We checked the records of finances held on behalf of the people who live at the home and found them to be satisfactory. The manager told us that she had plans to improve the frequency and system for staff supervision. Although checks showed that formal recorded supervisions were out of date we did notice that there were experienced seniors and a deputy who were accessible to care staff throughout the day. We asked staff “Does your manager meet with you to give support and discuss how you are working?” 4 said “Regularly” 1 said “often” and 2 said “sometimes.” We looked at a number of records held that showed that regular maintenance and servicing checks are completed. We also talked to the handyman who showed us the records of checks that he is responsible for. The home has been awarded 5 stars in the Tees Valley Food Hygiene Awards. The Environmental Health Officer visited in January 2008. Elwick Grange DS0000070551.V356881.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 X 3 X 3 X 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 3 4 5 Refer to Standard OP1 OP7 OP12 OP14 OP36 Good Practice Recommendations An induction leaflet with practical information should be developed for relatives. Care plans should be kept in a lockable facility. An activities programme should be provided that reflects the interests of the people who live at the home. Any restriction on a persons freedom is clearly identified within their care plan with an explanation of the rationale behind that restriction. Care staff should receive formal recorded supervision at least six times a year. Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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 Elwick Grange DS0000070551.V356881.R01.S.doc Version 5.2 Page 25 - 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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