Inspection on 14/02/07 for Manor Lodge

This inspection was carried out on 14th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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.

Other inspections for this house

Manor Lodge 20/12/05

Manor Lodge 15/07/05

Manor Lodge 16/11/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

The Garden House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Manor Lodge Manor Lodge 8 Portland Avenue Exmouth Devon EX8 2BS Lead Inspector Teresa Anderson Key Unannounced Inspection 14th February 2007 09:30 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 Manor Lodge DS0000062219.V313953.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. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Lodge Address Manor Lodge 8 Portland Avenue Exmouth Devon EX8 2BS 01395 266691 01395 277886 mail@manorlodgedevon.co.uk 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) Manor Lodge [Devon] Ltd Mrs Eileen O’Neill Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: Manor Lodge is a detached house in a quiet residential avenue in Exmouth. It is within walking distance of both the sea front and town centre. It is also very close to a regular bus service and the town also has a train service. This home provides personal care and accommodation for up to 23 older people. The accommodation is arranged over ground and first floors and all rooms have en suite facilities. There is a passenger lift and a stair lift between the ground and first floor. The lounge and dining rooms are on the ground floor. There is a large parking area at the front of the house and landscaped level gardens to the front and rear of the property. The latter has an extensive decked area used for sitting and for walking. Fees charged at this home range from £450.00 - £650.00 (double room rate) per week. This fee does not include items such as toiletries, hairdressing, newspapers and chiropody. Further information about this home, including reports, is available direct from the home. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place as part of the normal programme of inspection. The site visit began at 09.30am and finished at 5.00pm. Prior to the site visit the owners and manager provided information in a preinspection questionnaire. Questionnaires, asking for comments about the home, were sent to 10 residents and 7 were returned; to 10 staff and 9 were returned. Comment cards were sent to health and social care personal and none were returned. During the visit to the home the inspector spoke with or saw the majority of residents. The care and accommodation offered to 3 residents was case tracked (this helps us to understand the experiences of people using the service) and these people were spoken with in some depth. The inspector observed the care and attention given to residents by staff. She spoke with one of the owners (by phone), with the manager, deputy manager, 3 members of care staff, the cook and handyman and two visitors. She visited all communal and service areas in the home and saw approximately 8 bedrooms. Records in relation to care assessment, care planning, medication, fire safety and recruitment were inspected. What the service does well: The information available and opportunities to visit this home before people make a decision about where to live are excellent. Each person is assessed and has their needs identified. The manager is clear about the home’s strengths and limitations and on that basis makes a decision about whether a person should be admitted or not. Staff are given information about each resident prior to them moving in so that they can meet their needs and can support them through this life changing time. Assessment information forms the basis of a plan of care that is frequently reviewed, added to and changed when needed. Each plan is individual to the person it relates to, is goal orientated and is focused on the resident, their needs and preferences. Each person living here is treated and valued as an individual. Residents are helped to remain healthy through appropriate referrals to health care professionals, exercise and by a staff group who support residents to remain active socially and intellectually. One resident commented that ‘healthcare needs are taken very seriously’ and there is clear evidence of this. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 6 Medication is safely managed and residents are supported, where they wish to, to manage their own medication in a way that suits them. Residents enjoy a varied social life and have strong links with the local community, often getting involved in fund raising and in ‘Exmouth in Bloom’ competitions. Visitors are made welcome and always invited to the many social events which take place in the home. The fresh food served at Manor Lodge is of a high quality, is largely locally grown and organic. Residents are very complimentary about the food and the cook. Some commented that they appreciate the flexibility of times and places they can eat. No complaints have been received about this home. Residents say they know how to make a complaint if this were needed and that any minor grumbles are taken seriously. They say that staff listen to them and take actions if needed and that this is done sympathetically. They say they feel safe and that everyone is treated very well. All staff receive training in safeguarding adults and show an excellent understanding of what abuse is and what to do if they suspected or saw abuse or if an allegation were made. Staff report there is a zero tolerance to any kind of abuse or ‘poor attitude’. The home is furnished, decorated and maintained to a very high standard. It is clean, bright and safe throughout. Staff are well trained and are employed in sufficient numbers to meet residents needs. They are recruited in a way that promotes residents safety and this includes ensuring that all staff have police checks and have references from previous employers. One resident commented that there is a ‘culture of kindness’ here. Another said that they would be happy to have any of the carers looking after them. The home is managed by a competent and experienced manager who has consistently demonstrated a high commitment to ensuring that staff are empowered to deliver an exceptionally high standard of care. Monthly meetings, quality assurance procedures and a good relationship with all residents ensure this home remains focused on the people who live here. What has improved since the last inspection? What they could do better: No requirements have been made following this inspection. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 7 It is recommended that all handwritten entries on medication charts are always signed by two people. 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. Manor Lodge DS0000062219.V313953.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 Manor Lodge DS0000062219.V313953.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. Quality in this outcome area is excellent. People who consider coming to live at this home will have enough information about the home before they make the important decision about where to live. Assessments of residents prior to admission ensure that staff have enough information in order to know and meet each individual’s needs and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Manor Lodge has produced a comprehensive brochure detailing the services offered which is available to all enquirers. The brochure is laid out in a logical sequence and is easy to read and understand. The manager has compiled and recently added a ‘frequently asked questions’ section which is very useful. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 10 In surveys all residents who responded say they had enough information on which to base their choice. They say they visited the home prior to moving in when thy liked, had been shown around, introduced to staff and residents, had revisited and had come to stay at the home on a trial basis. Residents undergo a comprehensive assessment prior to admission to ensure that this home can meet their needs. This information is shared with staff prior to admission so that they have a ‘pen picture’ of that person and can help them to settle in. Staff spoken with demonstrate an excellent understanding of how traumatic giving up one’s home and moving into a care home can be. They talked of how they can play a part in supporting residents through this time and also of how they can ensure that residents maintain their independence and privacy and therefore their dignity. Manor Lodge DS0000062219.V313953.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 excellent. The arrangements in place for planning resident’s care ensure that residents consistently get the care they need in a way that suits them and in a way that promotes their independence. The healthcare needs of residents are well met with evidence of multidisciplinary involvement. The systems for the management and administration of medications are well understood by staff and ensure that residents’ medication needs are met safely. Residents are treated with respect and personal support is offered in such a way as to protect and promote residents’ rights to privacy and dignity. This judgement has been made using available evidence including a visit to this service. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each person living at Manor Lodge has a plan of care based on a comprehensive assessment and a sound understanding of the needs and preferences of that person. Care plans are written in detail and include appropriate information regarding moving and handling, risk assessments, tissue viability and nutritional needs. These are well organised, easy to read and understand and are updated regularly. Each care plan also contains a ‘pen picture’ of the resident for quick reference and a ‘potted history’ for use if the resident needs emergency hospital treatment. This consideration given to ensuring effective communication both within the home and between different services is excellent practice. Staff demonstrate an excellent knowledge of residents needs, likes, dislikes, personal routines and idiosyncrasies. They are familiar with the content of care plans and contribute meaningfully to these. It was observed that care plans form the basis for the handover of information between staff promoting effective communcation. Staff say that they are never asked to care for someone outside their area of expertise and that they know what to do if a resident’s needs change. Residents say their care is well planned and that their needs are well met. They talk of how the doctor is contacted for them if and when needed and that the manager appropriately takes advice from other sources. One resident said that healthcare is ‘taken very seriously’. Plans in place to meet one resident’s needs show a real regard for their mental health and an understanding of the person they are. Residents say they have a key worker and understand their role describing this as the person who ‘co-ordinates everything’, such as care, hospital appointments and shopping. Some residents talked of the excellent night care. Others talked of the ‘little extras’ such as how everyone has the offer of having their legs creamed at night to prevent dry skin. Residents say their privacy and dignity is maintained. For example staff always knock on their bedroom doors and wait for an answer before entering. They talked of staff kindness, respect and mutual regard. The inspector observed respectful interactions and saw staff treating residents with respect and great understanding. The manager reports that the home has recently undertaken a survey regarding privacy and dignity, to which the residents responded very positively. The inspector was shown the current system for managing medications. There is a set policy and procedure in place. Records of medications ordered, received, administered and returned to the pharmacy are kept. One resident said that they think medication is particularly well managed. They said that the medicines are always available, are given on time and staff have good Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 13 knowledge about the medications they are handling. All residents undergo a risk assessment to determine the degree to which they can manage and administer their own medication. This is in line with the ethos of the home which is to promote independence. Five residents currently manage their own medication. Whilst medication administration records checked are up to date there were one or two areas where good practice could be further improved. This includes making sure that all hand written entries are always signed by two people and further improving the system for recording controlled medicines. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 14 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. Links with the local community are good; visitors are welcomed and residents, on the whole, have their social care needs met. Support is offered in a way that promotes choice and flexibility. The meals offered provide choice, variety and meet nutritional needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In surveys 2 of the 7 residents who responded said that there are always activities arranged by the home that they can take part in. The other 5 said that there usually are. When asked residents did not have any suggestions for improving the programme of activities. ‘Grumbles’ seemed to centre around the bad weather, the winter months and therefore not having access to the gardens, seafront and town. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 15 The manager and staff are aware that some residents feel ‘stir crazy’ at times and make arrangements, often using their own transport, to get people out as much as they can. Arranged activities include entertainment each afternoon, an exercise programme, a library service (including talking books), poetry classes, musical appreciation, church services and outings to local amenities. Some residents belong to outside clubs and/or associations and are supported to attend these. Visitors report that they are always made to feel welcome. They say they are always offered refreshments and can join their friend/relative for a meal if they wish. The home produces a monthly newsletter that residents say they really enjoy. There is an events table where this and details of events, church news and diary dates are kept. On the day of this inspection Valentines Day was being celebrated. There was music and dancing; the dining room had been decorated with decorations made by residents and staff, the cook had made heart shaped biscuits and cakes and each resident received sherry and a red flower. This home has strong links to the community and the majority of residents are from the local area. The home enters (and usually wins) the Exmouth in Bloom competition, undertakes fund raising for local and national charities and recently hosted a visit from the local MP. In addition the home produces its own pantomime at Christmas to which friends and relatives of both residents and staff are invited. In surveys residents say they always or usually like the meals at the home. Some residents say that the quality of food is very good but that the reality is catering for a large number of people will always result in some not being completely satisfied. Other residents say that alternatives are always offered, that meal times are flexible, that meals can be taken where residents like, that ‘food is good and well cooked’ and that the cook is always very accommodating. All foods are sourced locally and are mostly fresh and organic. Residents are given ‘suggestion sheets’ where they make suggestions which are incorporated into the menu planning. Residents are offered tea and coffee making facilities in their rooms but none have so far taken this up. Manor Lodge DS0000062219.V313953.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): 16 and 17. Quality in this outcome area is excellent. The home has a satisfactory complaints system that residents feel confident in using if they need to. Residents feel safe and well cared for and staff’s knowledge of adult protection ensures that residents live in an environment where they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been received by the home or by the commission. In surveys all residents say that they always know who to speak with if they are not happy, that they always know how to make a complaint and that staff always or usually listen to them. One person commented ‘ staff are always ready to listen and sympathise and all worries are immediately taken to the manageress and remedied sympathetically’. All residents spoken with echoed this view. One resident commented ‘ the only thing I have to complain about is that there is nothing to complain about’. Residents say they feel safe and well cared for. One resident said that no matter what the resident’s ability and no matter how demanding that staff are Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 17 always kind, thoughtful and helpful. Staff demonstrated an excellent understanding of what abuse is and a good and confident knowledge of what to do if they suspected abuse or an allegation were made. Emergency contact numbers are available and staff have easy access to them. Manor Lodge DS0000062219.V313953.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): 19 and 26. Quality in this outcome area is good. The environment of this home provides residents with a homely, clean and safe place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Manor Lodge is decorated and maintained to a very high standard indeed. In surveys and in conversations all residents say how ‘lovely’, ‘beautiful’ and ‘perfectly clean’ the home is. One resident commented that the standard and type of décor has created a ‘lively, interesting and personal atmosphere’. Communal facilities are made up of a large lounge, divided into seating areas where there is a large screen TV. The dining room is largely glass with views to Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 19 the front of the house. Tables are laid and dressed to a high standard. Throughout the home there are small seating areas where residents can rest. Bathrooms and toilets are well equipped with aids to promote independence and with equipment to assist both staff and residents. Residents are very proud of the extremely well maintained gardens and seating areas. This includes extensive decking, onto which some rooms open, and which residents use for walking and exercising. Many residents continue to enjoy using their skills in the garden, their contribution depending on their abilities. One resident has planted a magnolia tree which they hope to see flower. Part of the garden is dedicated as a ‘Garden of Remembrance’ where residents can plant shrubs in memory of friends and loved ones. Staff have a good understanding of how to control infection and were seen putting this into practice. The laundry is tidy and clean and residents say their clothes are cared for extremely well. The manager has yet to assess the building in relation to equal access for disabled people and it is for this reason that this outcome has not yet been judged as ‘excellent’. Manor Lodge DS0000062219.V313953.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): 27, 28, 29 and 30. Quality in this outcome area is good. Staff receive appropriate training and have the skills to ensure that they are able to make residents lives as comfortable as possible. They are employed in sufficient numbers. The recruitment procedures designed to protect residents are followed, ensuring residents’ safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager provided information detailing the amount and type of training that staff receive. This has included training in undertaking risk assessments, training in caring for people who are dying and training in safeguarding adults. The National Vocational Qualifications (NVQ) training in care programme continues and approximately 63 of staff have now achieved this to Level 2 or above. In addition two members of staff have recently qualified as ‘mentors’ offering their skills to support and supervise other staff. This shows a real commitment to ensuring staff have the appropriate skills to meet residents’ needs. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 21 Staff demonstrate a good knowledge of the training they have undertaken indicating that they are putting this into practice and some practices have changed as a result of training received by staff. Residents are very complimentary about the staff and their skills, attitude and competence. One resident said ‘of course you have your favourites, but there is no one here that I wouldn’t be happy to look after me’. The duty rota shows that in addition to the manager, domestic and cook there are usually four members of care staff on duty in the morning, three in the afternoon and one waking and one sleeping member of staff at night. Residents say they get the care they need and that staff are always very good at night if they wake. Three recruitment files were looked at and all contained the necessary checks to promote residents safety. This includes police checks, references, a photograph and a completed application form. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 22 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 excellent. The management systems in place help to ensure residents live in a wellmanaged, safe environment where they are protected and where their quality of life is enhanced. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of Manor Lodge has completed the Registered Managers Award and has years of experience working with and supporting the elderly. She demonstrates excellent customer relationship skills and understands her role, her strengths and her limitations. The management structure she is part of Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 23 ensures that skills are shared, that staff are empowered and that the home is run in the best interests of the people who live here. The manager ensures that residents’ views are heard by holding monthly residents meetings and canvassing views formally. However, she understands that not everyone would choose these platforms to air their views. For that reason she has established a personal relationship with each resident and ensures that each resident has a key worker that they can work closely with. Both staff and residents are very complimentary about the managers style and the overall management of the home. One person commented ‘this is a good place to live’ another said ‘this is an excellent care home where there is a culture of kindness’. Staff commented that the home has ‘excellent management’ and another that ‘nothing at all’ could be improved. The owners are very involved in the running, maintenance, upkeep and in maintaining and improving standards in the home and in the care provided. Residents talk very fondly of them and staff say ‘no expense is spared’. This home holds the ‘Investors in People’ award and has been asked to become ‘champions’. This means showing other organisations how this award and this standard of excellence can be achieved. All staff receive mandatory training including fire training, food hygiene, infection control and first aid. Fire drills are undertaken frequently and staff show a good understanding of what to do in the event of a fire. Risk assessments of the building have been undertaken and actions taken to minimise risk. Whilst not all radiators are guarded to prevent accidental scalding, the risks posed have been assessed and the owners are committed to an on going programme of covering these. Following a lightning strike the manager has produced an exceptional ‘disaster plan’ which staff know where to find and how to follow. At this time all residents manage their own finances and are provided with secure facilities to keep their valuables. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 24 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 4 x 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 3 3 x x x x x x 4 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 4 4 4 x 3 x x 3 Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations You should ensure that all handwritten entries on Medication Administration Records are always signed by two people. Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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 Manor Lodge DS0000062219.V313953.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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