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Inspection on 17/07/07 for Ernelesthorpe Manor & Lodge

Also see our care home review for Ernelesthorpe Manor & Lodge for more information

This inspection was carried out on 17th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

The managers of the service provided comprehensive assessments. This ensured that the service have sufficient information to be aware of the service user`s needs prior to admission. Service users and relatives were satisfied with the care they received. Their opinions were: `The care is good / very good / excellent`. (Comments by five service users and four relatives) `They look after me very well`. Activities were organised within the service, which would provide stimulation to service users and enhance their quality of life. On discussing the activities with the service users, their opinions were that; `We have bingo which I really enjoy and won two prizes last week`. `Yes we do lots of things, its very good`. `We go out to the shops with the staff`. `I prefer to stay in my room, but the activities girl comes to see me`. `I have only recently moved into the home and I am a Jehovah`s Witness and want to visit attend my church and other meetings, my friends who are visitinghave agreed to collect me, and I`m sure the staff and the home will make sure that I can attend`. Service users were given the opportunity to exercise their right of choice regarding the provision of meals. Positive comments were received from the service users regarding the food provision. The general comments were that; `There is always a choice, mostly two sometimes three`. `The meals are good and there is a lot of variety`. `I eat my meals in my room and they bring me what I like`. `Yes we always know what meal we have ordered and they bring that one`. The environment, monitored at the site visit, had been maintained to a good standard and provided a safe, well-maintained environment for services users. The service users` rooms were homely and had been personalised and contained photographs, personal belongings, which the individual or the family had provided. There was a very pleasant, relaxed, friendly atmosphere within the home. Positive comments were received from the service users and relatives regarding the home. `The home is nice and clean`. `My room is nice`. `It`s spotless here`. `The rooms are always kept clean and tidy`. The staff recruitment process should provide protection for the service users. Positive comments were received from the service users and relatives regarding the staff. The general comments were; `They are good /always kind`. `Very caring`. `They are polite`. `Always there when you want anything`. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. Extensive quality assurance systems were in place that should assist the managers and company to measure the service against expected outcomes.Ernelesthorpe Manor & LodgeDS0000055879.V344830.R01.S.docVersion 5.2Page 7

What has improved since the last inspection?

The service acted positively on the requirements made at the last inspection. The bath panel had been replaced. The record of the agency staff working at the home had been produced. The staff files for staff appointed recently had a full employment history. All staff had received fire training. The manager had meetings with the staff and emphasised the importance of securely storing away cleaning substances.

What the care home could do better:

Accurate care plans need to be developed. This will contribute to the delivery of care. The manager was not able to provide evidence that all staff had received the necessary training, which could reflect on the quality of care being delivered to the service users.

CARE HOMES FOR OLDER PEOPLE Ernelesthorpe Manor & Lodge Cow House Lane Armthorpe Doncaster South Yorkshire DN3 3EE Lead Inspector Ivan Barker Key Unannounced Inspection 17th July 2007 11:00 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 Ernelesthorpe Manor & Lodge DS0000055879.V344830.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. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ernelesthorpe Manor & Lodge Address Cow House Lane Armthorpe Doncaster South Yorkshire DN3 3EE 01302 834643 01302 830800 NONE 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) Yorkshire Property Investment Fund Ltd Mrs Irene Widdowson Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65), Physical disability over 65 years of age of places (65) Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One specific service user under the age of 65, named on the variation dated 25th May 2004, may reside at the home. One specific service user under the age of 65, named on the variation application dated 4th July 2005 be accommodated at the home 20th July 2006 Date of last inspection Brief Description of the Service: Ernelesthorpe Manor and Lodge Care home is situated in a residential area in the village of Armthorpe in Doncaster. It is accessible by public transport and to local shops and other community facilities. The home is designed in a bungalow style and offers all its accommodation on the ground floor. Within the Home, there are two units, the Manor and the Lodge, but there is no physical division between them, only different corridors of the same building. One of the units accommodates service users who require personal care only. The other unit is for service users who have nursing needs. The fees are between £380.62 and £445.00. Items not covered by the fee include newspapers, hairdressing and private chiropody. The Statement of Purpose, and Service User Guide are available in all residents’ bedrooms and within the main entrance at the home. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’), and the previous requirements. The person present at the inspection was: Irene Widdowson, registered manager. Within this site visit, which occurred over a five hours and forty five minute period, the inspector toured the building, examined requirements relating to the previous inspection, case tracked 6 service users (Case tracked means looking at the care and service provided to specific service users living at the home; checking records relating to their health and welfare, care plans and other records; by talking to the service users themselves; viewing their personal accommodation as well as communal living areas), and spoke with other service users, and relatives and also 3 staff and examined assessments, care plans, risk assessments, menus, complaint files, staff files and quality monitoring documents. What the service does well: The managers of the service provided comprehensive assessments. This ensured that the service have sufficient information to be aware of the service user’s needs prior to admission. Service users and relatives were satisfied with the care they received. Their opinions were: ‘The care is good / very good / excellent’. (Comments by five service users and four relatives) ‘They look after me very well’. Activities were organised within the service, which would provide stimulation to service users and enhance their quality of life. On discussing the activities with the service users, their opinions were that; ‘We have bingo which I really enjoy and won two prizes last week’. ‘Yes we do lots of things, its very good’. ‘We go out to the shops with the staff’. ‘I prefer to stay in my room, but the activities girl comes to see me’. ‘I have only recently moved into the home and I am a Jehovah’s Witness and want to visit attend my church and other meetings, my friends who are visiting Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 6 have agreed to collect me, and I’m sure the staff and the home will make sure that I can attend’. Service users were given the opportunity to exercise their right of choice regarding the provision of meals. Positive comments were received from the service users regarding the food provision. The general comments were that; ‘There is always a choice, mostly two sometimes three’. ‘The meals are good and there is a lot of variety’. ‘I eat my meals in my room and they bring me what I like’. ‘Yes we always know what meal we have ordered and they bring that one’. The environment, monitored at the site visit, had been maintained to a good standard and provided a safe, well-maintained environment for services users. The service users’ rooms were homely and had been personalised and contained photographs, personal belongings, which the individual or the family had provided. There was a very pleasant, relaxed, friendly atmosphere within the home. Positive comments were received from the service users and relatives regarding the home. ‘The home is nice and clean’. ‘My room is nice’. ‘It’s spotless here’. ‘The rooms are always kept clean and tidy’. The staff recruitment process should provide protection for the service users. Positive comments were received from the service users and relatives regarding the staff. The general comments were; ‘They are good /always kind’. ‘Very caring’. ‘They are polite’. ‘Always there when you want anything’. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. Extensive quality assurance systems were in place that should assist the managers and company to measure the service against expected outcomes. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 7 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. Ernelesthorpe Manor & Lodge DS0000055879.V344830.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 Ernelesthorpe Manor & Lodge DS0000055879.V344830.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): Standards 3 and 6. People who use 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. Assessments with limited information from the care management team were in place. The managers of the service provided more comprehensive assessments. This ensured that the service have sufficient information to be aware of the service user’s needs prior to admission. EVIDENCE: On examination of the care management assessments within six care plans, it was established that all six had varying standards of care management assessments. Within one service user’s file, it had a copy of an assessment that related to the service user’s previous care at home assessment for domiciliary services and a one-page transfer sheet, which contained a few boxes that had been ticked. This transfer sheet had been provided by the hospital. The assessments were very limited in the information that was provided. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 10 The manager or deputy manager had undertaken comprehensive assessments of each service user prior to their admission. These assessments detailed the service user’s needs that would assist in the service having sufficient information for them to decide if the service could met the service users needs and provide sufficient information for care plans to be drawn up. The manager advised that no intermediate care was provided within the service. Ernelesthorpe Manor & Lodge DS0000055879.V344830.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): Standards 7, 8, 9 and 10. People who use 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. Accurate care plans need to be developed. This will contribute to the delivery of care. Service users were satisfied with the care they received. EVIDENCE: On examination of the care plans, from six service users, it was established that there were not daily entries within the care plans. Some of the entries had gaps of more than a few days or a week. However it was established that all six care plans had been evaluated on a monthly basis. The information which should be included in the daily entry is the evidence that the care prescribed in the care plan was delivered and that any changes in the needs relating to the health and personal care of the service users are recognised and recorded, so that the care plan may be correctly evaluated Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 12 using all the information, as the service user’s condition changes or at least on a monthly basis. The daily entries should reflect the current status of the service users health and well being. The manager agreed with the observation and immediately discussed the situation with her deputy manager and the qualified nurse. Comprehensive risk assessments were included within the documentation. The manager demonstrated a ‘care summary planner’, which was a document used to monitor if the care plans and risk assessments had been evaluated on a monthly basis. The document was clearly assisting staff as all the documents had been evaluated on a monthly basis. The quality of the care plan evaluation had to be questioned, because of the lack of information because of the gaps in the daily records. Service users and relatives expressed their views, during the inspection. Their opinions were; ‘The care is good / very good / excellent’. (Comments by five service users and four relatives) ‘They look after me very well’. The storage, ordering, administration and disposal of medication procedures were discussed with the manager. The procedures explained by the manager were satisfactory. There was a signature-checking document, which contained the initials as written on the medication administration document and the member of staff’s signature. On examination of the medication administration records it was found that there were no omissions of signatures. All medication records had been signed when being checked in from the pharmacy. Ernelesthorpe Manor & Lodge DS0000055879.V344830.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): Standards 12, 13, 14 and 15. People who use 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. Activities were organised within the service, which would provide stimulation to service users and enhance their quality of life. Service users were given the opportunity to exercise their right of choice regarding the provision of meals. EVIDENCE: The manager advised that an activities co-ordinator was employed for 16 hours per week. The hours worked were spread over seven days. The majority of her time was spent working between the days of Monday to Friday, three to three and a half hours per day, in the morning period. The activities coordinator also worked at the weekend when barbeques and fetes were organised. The service users had the opportunity to express their preferred activities through the service user meetings which occurred on a regular basis and had minutes taken. The manager advised that following these meeting the Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 14 activities co-ordinator would plan the activity sessions. Also the ‘relatives group’ organised and ran a weekly bingo session for benefit of the service users. Other activities and events within the service consisted over ‘motivation classes’ on Friday afternoons and on Tuesday on a fortnightly basis there was exercise to music. Singers were organised throughout the year. Also a company called ‘Zoo Lab’ visited 6 monthly and brought in small furry animals, snakes and other small creatures. The manager identified that the service users enjoyed the visits by the company and that the ‘different’ type of entertainment did benefit the service users. Outings were organised. Some service users had been on a boat trip in May and there a planned trip to Cleethorpes on the 3rd August 07. The manager advised that the resort was very popular with the service users. On discussing the activities with the service users, their opinions were that; ‘We have bingo which I really enjoy and won two prizes last week’. ‘Yes we do lots of things, its very good’. ‘We go out to the shops with the staff’. ‘I prefer to stay in my room, but the activities girl comes to see me’. ‘I have only recently moved into the home and I am a Jehovah’s Witness and want to visit my church and other meetings, my friends who are visiting have agreed to collect me, and I’m sure the staff and the home will make sure that I can attend’. Regarding the meals, the choice of meals was displayed on the menu boards outside each of the two dining rooms. The manager advised that either the cook or the care staff asked the service users for their choice of meal and this was recorded on a menu sheet and taken to the kitchen. The menu sheet for the day of inspection was observed. Copies of four weekly menus were seen, within the kitchen, and the food on the date of the visit was being prepared according to this menu. Positive comments were received from the service users regarding the food provision. The general comments were that; ‘There is always a choice, mostly two sometimes three’. ‘The meals are good and there is a lot of variety’. ‘I eat my meals in my room and they bring me what I like’. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 15 ‘Yes we always know what meal we have ordered and they bring that one’. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18. People who use 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 service had a complaints procedure in place, and it was operating according to the company policy, This would provide confidence that complaints were taken seriously and acted upon to address any shortfalls in care or service provision. The service was able to evidence that the staff had received safeguarding adults training. Therefore staff would be aware of their responsibility regarding the protection of vulnerable adults. EVIDENCE: The service had a complaints procedure within their ‘Welcome pack’ and Service User Guide which was available to service users, relatives and visitors. The procedure was also displayed at the entrance to the home. On examination of the complaint file it was established that the documents within the file contained the expected information; for example, the date of the complaint, the complaint and the details of the person making the complaint, the action taken, and the date the complaint completed. Any further information was attached to the complaint document. There had been one complaint regarding care and this had been investigated by the manager. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 17 Regarding safeguarding adults, the safeguarding policies and procedures were available within the manager’s office. Staff had undertaken safeguarding adults training, and the manager was able to evidence this. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 18 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): Standards 19 and 26. People who use 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 environment, monitored at the site visit, had been maintained to a good standard and provided a safe, well-maintained environment for services users. EVIDENCE: On touring the building, the manager advised that there had been considerable investment in the redecoration of the home. The home had been decorated throughout to a high standard, on the walls. It was clean and odour free. However it was agreed that the majority of the doors were looking tired and had sustained some damage over the years since the home was first built. Also the border paper of the dining room was torn. The manager advised that she thought that the dining room and the doors were part of the next plan for refurbishment of the home. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 19 Also whilst touring the home, it was observed that contracting staff were working on a problem with the fire exit signage, and the maintenance man was undertaking minor repairs. It was therefore recognised that repairs were quickly acted upon. Also one visitor raised the issue of a service user’s clothing drawers needing attention. On sharing this information with the manager, she informed the maintenance man. The service users’ rooms were homely and had been personalised and contained photographs, personal belongings, which the individual or the family had provided. There was a very pleasant, relaxed friendly atmosphere within the home. Positive comments were received from the service users and relatives regarding the home. ‘The home is nice and clean’. ‘My room is nice’. ‘It’s spotless here’. ‘The rooms are always kept clean and tidy’. The previous requirement from the last report had been acted upon. The bath panel had been replaced. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30. People who use 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 staff recruitment process should provide protection for the service users. The manager was not able to provide evidence that all staff had received the necessary training, which could reflect on the quality of care being delivered to the service users. EVIDENCE: On examination of the staff rotas and the number of staff on duty, the following was established: Am shift. Manor Unit: Lodge Unit: Pm shift. Manor Unit: Lodge Unit: Ernelesthorpe Manor & Lodge 2 qualified nurses plus 6 care staff. 1 senior care staff plus 3 care staff. 2 qualified nurses plus 5 care staff. 1 senior care staff plus 3 care staff. DS0000055879.V344830.R01.S.doc Version 5.2 Page 21 Night shift. Manor Unit: Lodge Unit: Plus The manager Activities Co-ordinator Administrator. Ancillary staff included. Domestics, catering staff and laundry. Caring for 32 service users, on the Manor Unit and 24 service users on the Lodge Unit. A full assessment of the dependency levels of the service users was not undertaken and compared with the indicated staffing levels. However the manager did identify that the dependency of the service users was quite high, as palliative care was provided to several service users and the staffing levels reflected the increase in the dependency level. Positive comments were received from the service users and relatives regarding the staff. The general comments were; ‘They are good /always kind’. ‘Very caring’. ‘They are polite’. ‘Always there when you want anything’. On examination of the four staff files, two of the staff files only had one reference in each file. It was established that the two staff had been employed within the service for a considerable number of years. The two other staff files contained two references. The manager identified that the two files with only one reference had been employed for over 8 years, and that staff employed recently had two references within their files. On examination of the files it was established that they contained the required documentation, including Criminal Records Bureau and POVA (Protection of Vulnerable Adults) checks, except for the references as stated above. 1 qualified nurse plus 3 care staff. 1 senior care staff plus 3 care staff. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 22 Therefore a requirement was not made regarding the staff files as the system were in place to obtain all the required information. On requesting to exam the staff training records the manager produced a training file and a matrix. Within the matrix it clearly identified the members of staff and the training that had been undertaken and the training yet to be completed this year. On examining the moving and handling training file it was established that some staff had not received training, since 2005. The manager advised that there had been a discussion with the training company that moving and handling may be every two years. It was discussed about proving competence of staff and protecting the company. Following this discussion the manager agreed that annual training might be better. The previous requirements from the last report had been acted upon. The record of the agency staff working at the home had been produced. The staff files for staff appointed recently had a full employment history. All staff had received fire training. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35 and 38. People who use 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. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. Extensive quality assurance systems were in place that should assist the managers and company to measure the service against expected outcomes. EVIDENCE: There was a registered manager in post. She advised that she had 35 years experience in care and 7 years experience in management and had completed the Registered Manager’s Award. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 24 Regarding service users monies there was a credit and debit system in operation. The system operated by using separate plastic pouches for storage of monies and individual accounting sheets for each service user. Some service users had monies held with the Local authority. The administrator advised that although she could obtain small amounts of money on request from the Local Authority, she was unable to obtain balances of these accounts. She identified that service users had requested that she obtain the information on their behalf, but she was unable to provide it until she asked for an amount greater than the service users current balance. This practice would appear to conflict with the service users’ rights to their own monies. The administrator identified that she would pursue the matter further and if necessary seek further advice and support on this matter. The importance of ensuring the use of service user’s money to enhance their quality of life, and not being left accumulating in the account, and the new bulletin ‘In safe keeping’ published by CSCI was discussed. Regarding Quality Assurance, there was a monthly analysis of activities, environment, medication, infection control, and other areas of the service. Monthly questionnaires were given out to the service users and 3 monthly questionnaires were sent out to relatives and professions, including GPs. It was discussed that as part of the quality assurance that a monthly analysis of the care plans may assist in monitoring if the daily entries had been made. Meeting with staff and residents occurred, which had minutes recorded. Regulation 26 documentations, which are a record of the registered person’s monthly visits, was complied on a monthly basis, evidence of this was seen at the visit. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, including falls, accidents etc; have been received by CSCI (Commission for Social Care Inspection). The Annual Quality Assurance Assessment (AQAA), which is a self-assessment document, which the manager of the service completes prior to an inspection, was completed and returned within the specified time. The previous requirement from the last report had been acted upon. The manager had meetings with the staff and emphasised the importance of securely storing away cleaning substances. Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Daily entries must be made to reflect the current status of the service users health and well being and provide accurate information for the monthly evaluation of care. All staff must receive annual training in moving and handling. Timescale for action 24/07/07 2 OP30 18 17/08/07 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 Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Ernelesthorpe Manor & Lodge DS0000055879.V344830.R01.S.doc Version 5.2 Page 28 - 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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