Inspection on 12/11/08 for Dryclough Manor

This is the latest available inspection report for this service, carried out on 12th November 2008.

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

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

Other inspections for this house

Dryclough Manor 16/01/07

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOMES FOR OLDER PEOPLE Dryclough Manor 20 Shaw Road Royton Oldham Lancashire OL2 6DA Lead Inspector Joe Kenny Unannounced Inspection 12th November 2008 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 Dryclough Manor DS0000067060.V373023.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. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dryclough Manor Address 20 Shaw Road Royton Oldham Lancashire OL2 6DA 0161 626 7454 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) drycloughmanor@yahoo.co.uk Dryclough Manor Ltd Miss Jacqueline Byrne Care Home 42 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (42), of places Physical disability over 65 years of age (6), Sensory Impairment over 65 years of age (4) Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 42 service users to include: *up to 42 service users in the category of OP (old age not falling within any other category). *up to 22 service users in the category of DE(E) (dementia over 65 years of age) 28th November 2007 Date of last inspection Brief Description of the Service: Dryclough Manor is a privately owned care home, registered to accommodate 42 people. The home is situated a short distance from the centre of Royton, near to a junction of two main roads, and is within easy reach of shops and public transport services. The home can be accessed from Mount St , Off Rochdale Road, turning immediate left down Eleanor Rd. The building is a detached property with pleasant gardens, a patio area and car parking space to the front. Accommodation for residents is provided on the ground and first floors, with two passenger lifts in operation. The home has 38 single bedrooms and two double bedrooms; 36 of the rooms have en-suite facilities, with two of these being shared. There is ramped access to the front entrance. The weekly fee is £395:00 for private fees and £360:00 for service users funded by local authority. The fees do not include the following: hairdressing; toiletries; chiropody. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced site visit took place over eight hours, on the 12 November 2008. The registered manager was present throughout the inspection. Files relating to people recently admitted and a random selection of files for people who have resided there for some time were looked at. Additional records relating to staff, medication and health and safety were also looked at. The manager completed and returned a self-assessment of how national minimum standards were being met, with additional information about the service they provide and staffing information. The inspection also looked at information received by the Commission in relation to the home prior to the visit. A number of comment cards were forwarded to people living there and to staff as a further means of seeking their views. The information received is included in this report. Time was taken to speak with relatives, staff and people living in the home. A brief tour of the home and grounds was also undertaken. What the service does well: The home and its grounds offer people a well maintained and homely environment to live in. Staffing levels at the home were commendable in terms of cover and support provided to people throughout the day; this also related to appropriate ancillary hours. It was evident that people could access their rooms when they wished and a number of people confirmed they had a key to their own bedroom. During discussion with visitors all indicated they were provided with information about the home and had supported their relative to move there. A number of service users confirmed they had chosen to live there. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 6 The manager described her involvement in the admission and assessment process and confirmed that the process enabled the home to determine if people’s needs could be met by the home. Residents and relatives passed positive comments on the meal and menu arrangements. Information on daily menu plan is displayed and the cook was observed consulting with service users prior to preparing the evening meal. What has improved since the last inspection? What they could do better: Advice must be sought form the local fire service regarding fire safety arrangements. It is advised that programmes of supervision and meetings are formalised with records maintained of outcomes. It was advised the key workers are encouraged to progress person centred care planning and that staff are encouraged to seek and record peoples’ views about how they want to be supported. Noted improvements in the management and administration of medication should be supported by regular monitoring and audit of medication. There is a need to ensure training programmes relating to The Mental Capacity Act are provided to staff. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 7 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. Dryclough Manor DS0000067060.V373023.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 Dryclough Manor DS0000067060.V373023.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): 3. Standard 6, not applicable to service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission and assessment procedures ensure people are provided with satisfactory information about the home and people’s needs are identified before a service is offered. EVIDENCE: There were no vacancies at the home at the time of the visit. Information about the home had been reviewed since the last inspection. This included review of the statement of purpose and service users guide. Information about the home and previous inspection reports are located in the foyer for people to read. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 10 Referrals are received from social services and a plan of care is then received by the home. The manager is directly involved in the admission process and meets with people to discuss their needs and complete the home’s admission documentation, leading to the development of the individual’s care plan. Discussions were held with the manager on the need to ensure the home can meet the needs of those service users with dementia and that staff have the necessary skills and knowledge base to meet and respond to such care needs. People are encouraged to take up a trial visit or attend the home to have a meal. This allows people to look around the home and meet other service users and staff. During discussions with service users and relatives, a number of people confirmed they had been offered the opportunity to visit other services before deciding to move to Dryclough Manor. Each person is provided with a service user’s guide on admission. A Customer Enquirey form is used for all referrals and is completed even if the person does not choose to stay. This is a positive way of evidencing people are offered the opportunity to visit the service. A number of contracts and statements of terms and condition of placement were seen. Documents were signed on admission and the manager was advised to ensure an amendment to fees is retained on the persons file. Documents should also be dated and record the persons room number. A selection of files were examined including the files of two people most recently admitted. Information was informative and outlined people’s need for care. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care needs are recorded in care plans and are drawn up in consultation with people or their representative. EVIDENCE: The care plans of four service users were looked at, including the files of two people recently admitted. The information was informative, using information received at the time of admission, from the initial assessment and pre admission information assessed by the home. Relatives confirmed they were involved in discussions relating to peoples needs. The plans identified specific care needs and the level of care and support each person needed. Staff spoke about person centred care planning, however, the records seen needed to evidence development of care planning in a more person centred Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 12 format. The home does support people using the key worker system whereby individuals are allocated named staff members as their key worker. This should allow staff the time to work with people living there to discuss how people wished to be supported on all aspects of daily living. Records also contained information about specific health care needs and contact details for family and other health professionals supporting them. There were three entries per day on the care records. Throughout the day observations were made on the way staff and people living there interacted. There was a positive and professional approach taken by staff when supporting people. Staff were observed to consult with people when supporting or assisting them. Relatives said they were confident that staff and the manager would keep them informed of any changes in the health care needs of their relative. A number of additional records for individuals were held in separate record books, diaries and ring binders. This information related to toileting and bath records, weight records and document developed by Oldham Primary Care Trust. The manager was advised to transfer and hold such records within the individual files of named service users as opposed to a communal record. Where planning toileting programmes are established, it is advised to retain evidence that the planned period so support are maintained by staff. The process for archiving records should be reviewed. The manager was advised to retain records on file for a greater length of time than is current practice. This is necessary on order to build up a picture of health care events such as accidents, in terms of number and frequency. Evaluation and review of care plans on a number of areas read “ensure plan is followed”. It was advised that this should be more narrative in terms of the action to be taken by staff when supporting people. Medication administration procedures are overseen by designated senior staff, assistant manager or manager. Medication is stored in a secure area of the home. The senior on duty is responsible for medication and hold the key to the storage area. A copy of the home’s medication policy was located within the medication storage area. The manager had taken steps to review the document to ensure it provided staff with the information they needed when administering medication. The manager was advised to retain a sample record of staff signatures and initials and that this should be located at the front of the medication Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 13 administration records (MAR). Signature should be easily interpreted from other codes. It is recommended that the time of administering pain relief patches is stipulated on the medication administration record to ensure prescribed intervals are being maintained. Quantities of medication must be monitored and recorded on MAR sheets especially in relation to medication such as Warfarin where 1mg and 3mg medication is prescribed. Records are maintained of medication received by the home and when returned to the pharmacist. On examination of stocks of medication the home is advised to ensure correct accounts of stock are maintained where amounts of medication are carried forward from the previous month. This related to liquid medication and some tablets. Where staff hand write information on to the medication administration records, these should be signed by the person making the entry and also be signed by another member of staff to confirm the entry is accurate and correct. The example related to medication entered as mg when it should have read mcg. The practice of removing medicines from its original packaging should cease as this practice made it difficult to audit stocks of medication. All records relating to medication required monitoring and the manager was advised to conduct more regular checks and audits of medication. This should also include checks on information within the controlled drugs register. It was also advised that ongoing refresher training and support is sought from the supplying pharmacist on auditing and management of medication. Dryclough Manor DS0000067060.V373023.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 good. This judgement has been made using available evidence including a visit to this service. Daily living and social care arrangements are relaxed and delivered to meet peoples’ needs and abilities. EVIDENCE: Throughout the visit, from observations it was evident that people are free to plan how they spend their day, such as what time they get up, where they sit and what activities they want to take part in. During discussions with people living there, staff and relatives, it was evident that a relaxed and homely environment was maintained. Although the abilities of people varied it was evident that social care arrangements were an important aspect of life in the home. An activities organiser is employed, working 22 hours per week and staff were also encouraged to spend time with people on activities outside of these allocated hours. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 15 The manager said staff are encouraged and given time to sit and talk to people as part of care delivery. The number of staff employed throughout the day is well maintained to enable staff to spend time with people. The opportunity was taken to speak with visitors, who said they were made to feel welcome when they visited and were kept informed of health and social care issues relating to the people they visited. Relatives and people living there complimented the home on the meals provided and said they appreciated the variety and choice on offer. Records are maintained to evidence the range of choices offered. People confirmed they were free to access their rooms and people are offered keys to their rooms. People living there spoke about activities they participated in. Two people spoke about an activity involving making cards for festive occasions and also spoke about fund raising events. They said they encouraged other people living there to be involved. It was encouraging to hear that people living there are involved in discussions relating to the use of funds raised and what events and activities such funds should be used on. Other activities included manicure sessions, hairdressing service, bingo, dominoes, trips out and escorted trips to shops where staffing levels enabled this to take place. A review and development of the key worker system should be undertaken to assist in progression of person centred planning to enable staff to give time to speak to individuals about their life experiences, personal and social care preferences. Meal arrangements are planned in consultation with service users and meals are taken in a well presented dining area with tables appropriately set out with table cloths and dishes and condiments. Breakfast times are based on people’s preferences as to when they wish to get up. Service users spoke about how they enjoyed their meals and confirmed they were asked about their preferences and any alternative choices. The menu for each meal is recorded on a white board in the dining area. During the visit the cook was seen to speak with individuals regarding their choice of meal. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 16 The cook confirmed and provided evidence that an alternative is offered and provided where requested. Records are retained of choices offered and preferences of each person on a daily basis. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place to listen to people views about the care they receive. Systems are in place to ensure people are protected from abuse or harm. EVIDENCE: The procedure for dealing with complaints is set out in the service user guide and is also available in information displayed in the reception area. During discussions with service users and relatives, they said that if they had any concerns they would speak to the manager or the assistant manager. Those people spoken with said they had no concerns about the care provided and were complimentary of the staffing levels at the home. The home keeps a register of any complaints it may receive. There were no complaints recorded for some time and no complaints had been received by the Commission in the period since the last key inspection. The manager stated that staff had been provided with training on matters relating to dealing with allegations of abuse. Staff spoke about training received on the topic as part of NVQ training award. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 18 Following discussions with staff on this topic, it is advised that the topic be discussed in supervision and staff meeting sessions to ensure staff are provided with any additional support they may need. Some responses by staff, to examples used during discussion, indicated staff may not take appropriate action. However, staff did conclude by saying they would take any concerns to the registered manager of the home. Staff did have a good understanding of whistle blowing procedures. On examination of care plans, discussions were held with the manager in relation to recorded information which may indicate that an incident recorded should have been referred for investigation under safeguarding procedures. There was a need to ensure also that such incidents are referred to the commission in accordance with Regulation 37 notifications of incidents relating to the wellbeing of service users. It is advised the staff receive additional training so they are aware of their responsibilities under Local Authority procedures. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. The home was well maintained and provided a comfortable and relaxed environment for people living there. EVIDENCE: The home is situated in pleasantly landscaped grounds. The original character of the manor is retained with extensions offering single room provision and a large lounge and dining facilities. As part of the inspection a tour of the home was conducted. Bedrooms were found to personalised and could be accessed throughout the day without restriction. People arranged their room to reflect their choice and preference. Furnishings and decoration were to a good standard and gave a homely feel. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 20 There are three different lounge areas to choose from and separate dining areas local to the lounges people use. The smaller lounge continues to be accessed by people requiring more regular support and supervision. Lounges were suitably furnished and offered people access to range of interests such as books, music systems and television. There are additional seats located in the entrance reception area and on one of the corridors on the first floor located close to the hairdresser’s room. The laundry and kitchen areas were suitably equipped and staffed. The call point was tested in the lounge, with a slow response by staff. In light of the number of staff on duty, regarded as good, this was an area which needs monitoring. At one point where the older building and new extension meet there was ramped are located close to a fire door. One accident was recorded of a service user having an accident near this area. It is advised that some form of hazard warning alert is located close to this area. On touring the building it was difficult to determine the way out of the building as there appeared to be a deficiency in fire sign directions. Advice must be sought from the local fire officer on this matter. It was also of concern that a number of doors were wedged open. This practice has the potential to delay fire containment when required and place staff and residents at risk. This practice must be reviewed as part of the homes overall fire risk assessment. All fire doors in the new extension are fitted with smoke seals. These are not present on door to the older building. Advice should be sought on the fitting of door closers and seals to these doors. There is a designated smokers room on the ground floor. A risk assessment should be carried out as to whether a restrictor requires fitting as an additional security measure. The grounds to the rear are paved and a large embankment rises and extends back. There is a make shift fence differentiating the grounds belonging to the home and property owned by the local authority. A risk assessment should be carried out in relation to security arrangements and any risk to persons wandering off the premises. Programmes of decoration are ongoing and overseen by a designated maintenance person based at the home. A gardener is also employed and the grounds were found to be well maintained and landscaped. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 21 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 excellent. This judgement has been made using available evidence including a visit to this service. Staffing arrangements were well maintained in terms of numbers and deployment of staff. Recruitment procedures ensured that service users were protected. EVIDENCE: The staff rotas for the period covering the inspection and the week following the visit were assessed. The deployment of care staff over a twenty four hour period was commendable, with a minimum of six staff on duty in the morning and five in the evening. During the night hours there are four staff on waking duty. The manager continues to be very much hands on care and part of her hours are taken up with administrative duties. The recently appointed clerical assistant will assist in freeing up her time to develop and progress policies and procedures and person centred planning. The employment of ancillary staff for domestic, catering and laundry duties ensure care hours are directed towards delivery of personal and social care needs of people living in the home. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 22 The files of staff recently recruited were examined . Appropriate reference checks were seen and confirmed to be in place, including Criminal Record Bureau (CRB) checks. The files are retained in a secure manner. During discussions with the manager on supervision programmes, the indications were that informal sessions and discussions are held with staff in relation to work practices. The manager is advised to develop more structured and formal supervision sessions with staff and to keep records of outcomes and topics discussed. It is also advised that minutes are retained of staff meetings. Information provided by the manager in relation to training was that progress had been made in relation to NVQ training for staff and that up to 70 of staff had now completed or were in the process of completing the award. During discussion on the development of person centred planning it is advised the training on the Mental Capacity Act is incorporated into planned training programmes. Relatives and staff said they felt there was enough staff to meet the needs of the people living at the home. The outcomes of discussions held with individual staff were positive. Staff spoke about the hands on support they received from the manager and their colleagues. Dryclough Manor DS0000067060.V373023.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): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration procedures ensure the home is run in the best interest of people who live there. EVIDENCE: The manager holds the necessary qualification and has a number of years experience in caring for older people. An assistant manager and a committed staff team support the manager. The manager is actively involved in all admissions to the home and confirmed that if the needs of a person referred could not be met the admission would not take place. Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 24 The recent appointment of an administration assistant to support the manager will assist her in the development of policies and procedures to support the positive work undertaken at the home. Procedures were in place in relation to provision of induction and training programmes for staff. Some induction programmes needed addressing for one senior staff recently appointed. All staff received mandatory training. Procedures were in place to ensure all equipment and services were regularly checked and maintained under contract. Records relating to health and safety checks and checks on the fire system were well maintained as were certificates relating to the service of the life and insurance liability. The home completes an annual consultation and survey of peoples’ views. The manager was advised to do a summary report of the finding to be included in the homes Statement of Purpose. Money held on behalf of service users is the direct responsibility of the manager. Dryclough Manor DS0000067060.V373023.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 3 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 4 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 2 Dryclough Manor DS0000067060.V373023.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 OP38 Regulation 13 Requirement To consult with the fire service on all aspects of the fire safety arrangements and procedures to ensure people are safe Timescale for action 07/01/09 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 OP3 Good Practice Recommendations Evidence should be retained that the home can meet the needs of service users with a dementia and that staff have the necessary skills and knowledge to meet and respond to such care needs. All records relating to individual should be held in one file and not as communal records. Programmes of intervention should retain evidence that periods of support are maintained by staff. The process for archiving records should be reviewed. The manager was advised to retain records on file for greater length of time than is current practice to build up a picture DS0000067060.V373023.R01.S.doc Version 5.2 Page 27 2 OP7 3 OP7 Dryclough Manor 4 OP17 of health care events. Plans of care should be more narrative in terms of the action to be taken by staff when supporting people. This related to records which read “ensure plan is followed”. Procedures relating to medication should be monitored in relation to areas identified in the health and personal care section of this report. of medication. Information on care plans, should be regularly monitored to ensure appropriate action is taken to information which may indicate that an incident should have been referred for investigation under safeguarding procedures. Any incident that adversely affects a resident at the home must be reported without delay to the CSCI. It is advised the staff receive additional training relating to protection procedures so they are aware of their responsibilities under Local Authority procedures. Issues relating to the premises needed attention in the areas identified in the environment section of this report. Staff should receive formal supervision so that their training needs can be identified and met. 5 OP13 6 OP18 7 OP18 8 9 OP19 OP36 Dryclough Manor DS0000067060.V373023.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Central Registration 9th Floor Oakland House Talbot Road, Old Trafford Manchester M16 0PQ 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. 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