Care Home: Ernelesthorpe Manor & Lodge

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What the care home does well People who use the service and their relatives are satisfied with the care and support that is provided at the home. There is a good and committed staff team, which works well together and other health care professionals, to ensure the health and wellbeing of people who live at the home. The service provides good training opportunities to its staff to make sure that they have the relevant knowledge and skills to provide care to people who use the service. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 The home is well managed and staff have use of good quality assurance procedures to ensure its continual improvement. What has improved since the last inspection? Since our last inspection (July 2007), the home has been refurbished and some parts upgraded. New equipment and facilities have been provided. The laundry area has been provided with new hand washing facilities and new flooring, in order to improve infection control procedures at the home. Staff training and development has progressed well. The deputy manager has also acquired her ‘Registered Manager’s Award’. Quality assurance procedures have been improved and staff are making good use of them in order to continue improving the service. What the care home could do better: Although there was a sufficiently robust care planning system in place, staff should ensure that the actions that they lay out to meet identified needs are clear and specific. Staff should make proper records of the care that they provide. These actions should help care staff in delivering care more effectively. They should also make sure that they evidence the review of individual care plans in a more appropriate manner. This should allow them to evaluate care provision more consistently and more effectively. There is a need to ensure that all complaints investigations are properly recorded and kept at the home. This should help in improving the overall complaints management and service improvement. There is a continuing need to improve the arrangements for the provision of meals and the dining room furniture. This should help to make the meal service more congenial and pleasant. Key inspection report CARE HOMES FOR OLDER PEOPLE Ernelesthorpe Manor & Lodge Cow House Lane Armthorpe Doncaster South Yorkshire DN3 3EE Lead Inspector Ramchand Samachetty Key Unannounced Inspection 16th July 2009 09:00 DS0000055879.V378861.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ernelesthorpe Manor & Lodge DS0000055879.V378861.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 manager@echd.eclipse.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) 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.V378861.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. 17th July 2007 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 manager confirmed that fees as at 16 July 2009 were between £387.00 and £496.00 per week. 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. Further information can be obtained from the home. Ernelesthorpe Manor & Lodge DS0000055879.V378861.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 Two Star. This means that the people who use this service experience Good quality outcomes. This key unannounced inspection was carried out on 16 July 2009, starting at 09.45 and finished at 18.00 hours. The manager, Mrs Irene Widdowson, was present and the regional manager also attended for some parts of this inspection. The service is registered for up to 65 older people. There were 59 people in residence at the home at the time of this inspection. All the key national minimum standards for ‘Care Homes for Older People’ were assessed. The inspection included a visual check of the premises, examination of care documents and other records, including staff rota, medicines management, complaints and maintenance of equipment and quality assurance methods. The care of three people was examined and some aspects of care were observed. We also checked some of the information contained in the ‘Annual Quality Assurance Assessment’ that was submitted to us before this inspection. We spoke to people who used the service and to relatives and staff. We gave feedback about our initial findings to senior staff, the registered manager and the regional manager. We would like to thank all the people living at the home, relatives, the acting manager and her staff for their assistance with this inspection. What the service does well: People who use the service and their relatives are satisfied with the care and support that is provided at the home. There is a good and committed staff team, which works well together and other health care professionals, to ensure the health and wellbeing of people who live at the home. The service provides good training opportunities to its staff to make sure that they have the relevant knowledge and skills to provide care to people who use the service. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 6 The home is well managed and staff have use of good quality assurance procedures to ensure its continual improvement. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ernelesthorpe Manor & Lodge DS0000055879.V378861.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 Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who used the service had their care needs appropriately assessed before they were admitted to the home. This ensured that identified needs could be met. EVIDENCE: The care files of three people who were more recently admitted to the home were checked. They showed that full assessments of needs had been carried out by both the placing social workers and staff at the home before their admission. This helped to establish that their care identified needs could be met at the home. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 9 The home does not provide an intermediate care service. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s personal and health care needs were appropriately catered for and took into account their preferences and wishes. However, there were a few minor shortfalls in the recording and reviewing of care provision. These could affect proper evaluation of individual care. EVIDENCE: People who used the service and their relatives told us that they were satisfied with the care and support that was provided at the home. They said that staff and in particular, the key workers, were ‘friendly and caring’. Relatives said that in their view, their loved ones were well looked after. People who lived at the home and who could express their views said that their personal care was always provided in a manner that protected their privacy and dignity. We observed some interactions between staff and the people in their care and Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 11 these were friendly and courteous. We found that people living at the home were in good attire and that the atmosphere was relaxed. We looked at the care plans of three people who used the service. They were broadly based on the identified care needs of the individuals concerned. They outlined actions that were required in order to cater for the personal and health care needs of people. However, in some instances, actions laid out to meet needs were not specific and clear enough to guide staff in providing all the required care. The care plans that we looked at, took into account the risks that people faced in their daily activities and also their preferences in the way care was provided to them. We noted that the stated preferences of people were appropriately observed. There were specific care plans for dealing with pressure ulcers and other specific health conditions. Care plans were regularly reviewed. However, the care plan reviews that we checked showed that they were not appropriately based on the evidence of care provided. In some instances, the records of care consisted of generalised comments and lacked information about the actual care provided. People who used the service and their relatives told us that staff were ‘proactive’ in ensuring that they had good access to the necessary health care services. These included the services of the local GPs, dentist, chiropodists, and district and community nurses. The care plans had records of the interventions of visiting health care professionals in relation to each person’s care. These records confirmed that people who used the service had appropriate access to community health care services when they needed them. We looked at the way medicines were stored, handled and administered at the home. Medicines received at the home were appropriately recorded and stored. We checked a sample of medicines administration records (MAR) sheets. These were appropriately maintained. None of the people living at the home at the time of our visit were administering their own medicines. The manager confirmed that care staff who administered medicines had received the required training to do so. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home were able to benefit from the recreational and social activities that were provided to them and these helped to maintain and improve their quality of life. EVIDENCE: During our visit, we observed people who lived at the home, spending time in lounges and in their own rooms, watching television, listening to music and reading or engaged in conversations. We also noted that some people were busy with visitors. On occasions, we observed members of the care team spending time, with the people in their care, on a one to one basis. People who lived at the home and relatives commented that they felt routines at the home were flexible. People could choose how to spend their day time and who they shared their time with. Staff explained that for people who could not make decisions about their day time activities, they would consult relatives Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 13 in order to find out their preferences and then ensure that these were catered for. The activities co-ordinator and other care staff explained that both indoor and outdoor activities were organised at the home. These included sing-along, movement to music, baking sessions, gardening and outings to places of interest. Some people told us that they had taken part in a boat trip and that they had enjoyed it. Peoples’ participation in the activities that were organised by staff was appropriately recorded in their care plan. Staff also commented that relatives were also encouraged to join in the various activities that were organised at the home and this helped to ensure social inclusion of people who used the service. Relatives confirmed that they were always welcomed at the home. They commented that staff, including the key workers, communicated well with them and this benefited their loved ones. People who lived at the home and their relatives stated that the meals prepared and served at the home were ‘good and nourishing’. People were given good choices of food and drinks for breakfast, lunch and dinner each day. A late supper was also provided for those who wanted it. The lunch time meal, which was the main meal of the day, was observed. It consisted of corned beef hash, toad-in-the-hole, mash potato and vegetables. Deserts consisted of bread and butter pudding and fresh fruit salad. Drinks of tea, coffee, fruit drinks and water were also offered. Staff were observed helping a few people to eat their meals and they did that in an unhurried manner. In discussion, we also noted that the nutritional needs of people had been appropriately assessed and catered for. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The views and concerns of people who used the service and their representatives were listened to. However, some records relating to complaints management were less robust and this could affect opportunities for more effective service improvement. People who lived at the home were appropriately protected from potential harm and abuse and this helped to maintain their health and wellbeing. EVIDENCE: There was a complaint procedure in place and copies had been provided to people who used the service and their relatives. People said that they were aware of the procedure and would use it if they needed to do so. Some people said that they had received appropriate support and encouragement to air their concerns and that they were satisfied with the prompt response from senior staff. The manager had stated, in the ‘Annual Quality Assurance Assessment’ document that was sent to us before the inspection, that the home had received thirteen complaints in the last twelve months prior to May 2009. We checked the way these complaints had been managed. The manager had Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 15 carried out the appropriate investigations and replied to the complainants. However, not all the investigations had been recorded and kept. There was also an adult safeguarding policy and procedures in place for staff guidance, in order to promote the safety and wellbeing of people who used the service. In discussion, staff said that they had received training on safeguarding and were aware of the local procedures to be used. Staff training records confirmed the provision of training on safeguarding issues. The manager confirmed that there had not been any safeguarding referral from the home. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who lived at the home and their relatives were satisfied that the accommodation provided was safe, clean, comfortable and pleasant. This helped to maintain and promote the health and wellbeing of people who lived at the home. EVIDENCE: We checked the premises in the company of senior staff. The home is designed in a bungalow style and offers all its accommodation on the ground floor. There were two units. One offered accommodation to people who required personal care only and the other one was for those who required both personal and nursing care. The communal areas included a few lounges and quiet areas. We Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 17 noted that each of the lounges had been provided with large screen televisions. Some people commented that this has made viewing much more ‘interesting’. We noted that the dining area was rather packed to capacity when it was in use. The limited space was further constrained because a number of people were at the dining tables with their wheelchairs. This led to some people saying that the seating arrangement was not ‘as good as it could be’. We also noted that the dining furniture was showing signs of increasing wear and tear. We viewed a few bedrooms with the permission of people who occupied them. The rooms were clean, tidy and well decorated. A few people had brought in some memorabilia and this helped to ‘personalise’ their bedrooms. They said that they were satisfied with their accommodation. Staff explained that the laundry facilities had been improved. New flooring and a new sink had been installed, in line with professional guidance and in order to improve the control of infection. We noted that both the communal and private areas in the home were kept clean and tidy. The surrounding grounds were also well maintained for the time of the year. These helped to make the place more pleasant and comfortable for people who lived at the home. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who used the service benefited from good staff recruitment and training and deployment arrangements. These ensured that they received appropriate care by skilled and competent staff. EVIDENCE: At the time of this inspection, there were 59 people in residence at the home. Thirty of them required both nursing and personal care and the others, only personal care. Besides the deputy manager, there were ten care workers on duty on the day shift. Five care workers and one first level general nurse were scheduled to work at night. There were other support staff on duty and they included the administrator, an activities co-ordinator, cooks and domestics. The deputy manager explained that the staffing level was based on the dependency of people who lived at the home and that the dependency levels were regularly assessed. More care staff were deployed at busy times to make sure that the needs of people were appropriately met. We looked at the duty rota and it showed that appropriate levels of care staff were consistently deployed on duty. In discussion, people who lived at the home and relatives Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 19 told us that, in their view, there were ‘always staff around’ and that people who required assistance were helped ‘without much waiting’. We looked at the files of three members of staff who had most recently joined the home. They showed that the appropriate recruitment and selection procedures had been used. All the checks, including written references and disclosures had been sought and obtained. The new staff members had been provided with induction and initial training to make sure that had the necessary skills and understanding to provide care to people who lived at the home. Information from the home’s ‘Annual Quality Assurance Assessment’ document (AQAA) that was sent to us before this inspection indicated that staff were being provided with a range of training, including ‘refresher’ training. We checked the training courses that had been provided to staff. It included courses on manual handling and moving, health and safety, adult safeguarding, mental capacity and the deprivation of liberty safeguards. The AQAA also told us that 20 of the 46 permanent care workers at the home had achieved their ‘National Vocational Qualification’ level 2 or above, in care. Also, other staff were undertaking this course. We noted that the care staff team comprised of people of diverse backgrounds and was able to meet diverse cultural needs well. Staff told us that they were satisfied with the training, supervision and personal development opportunities that they were receiving and that they felt well supported in the work they did. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate management arrangements were in place to ensure the proper day-to-day running of the home. This helped to maintain and promote the health and safety of people who lived at the home. EVIDENCE: The manager is a qualified first level general nurse and has experience in the provision of residential and nursing care of older people. She has completed her ‘Registered Manager’s Award’. She is supported by, a deputy who is also a first level nurse and who hold a ‘Registered Manager’s Award and a regional Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 21 manager. In discussion, people who lived at the home, relatives and staff spoke positively about the manager and her senior team. The manager explained that staff had use of various quality monitoring tools to help improve the service. These included monthly audits of care plans, medicines management, health and safety checks, maintenance of equipment and regular ‘service user and stakeholder’ surveys. The manager was also conducting staff and ‘Residents and Relatives’ meetings in order to get the views of people who lived and worked at the home. Action plans were developed, as necessary, in response to the findings of such audits and surveys. This helped to ensure that appropriate and timely remedial actions were taken to improve the service. The registered provider was also conducting appropriate monthly unannounced visits to the home. Reports of these visits showed that they were comprehensively undertaken and that they were also used as action plans to improve both the management and quality of the service. Arrangements were in place to support people with the management of their personal allowances. All financial transactions undertaken on behalf of people concerned were appropriately recorded, witnessed and signed for and receipts were kept. People concerned told us that they could access their monies when they needed it. The registered manager had submitted the ‘Home’s Annual Quality Assurance Assessment’ to us prior to this inspection. It showed that all appliances, utilities and equipment used at the home were appropriately serviced and maintained. Maintenance records confirmed that these checks were regularly carried out. Appropriate risk assessments and health and safety measures, including infection control, fire precautions, were in place and this helped to maintain the health and wellbeing of people who lived at the home. Ernelesthorpe Manor & Lodge DS0000055879.V378861.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 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 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 23 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 OP7 Good Practice Recommendations Actions to be taken to meet identified needs should be laid out in clear and specific terms. This should help care staff to provide care and support in a more consistent and effective manner. The record and review of care provided should be improved to reflect the contents of the agreed individual care plan and the evaluation of care given. This should help to continually improve the overall quality of care provision at the home. The investigations of all complaints should be appropriately recorded and kept at the home. This should help to ensure that all complaints outcomes are considered in quality assurance work. The seating arrangement at meal times should be reviewed to ensure the maximum comfort of people who live at the home. The home management should consider the upgrading of DS0000055879.V378861.R01.S.doc Version 5.2 Page 24 2. OP7 3. OP16 4. 5. OP19 OP19 Ernelesthorpe Manor & Lodge dining furniture in order to add to the comfort of people who live at the home. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 25 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshireandhumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Ernelesthorpe Manor & Lodge DS0000055879.V378861.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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