Inspection on 18/09/08 for The Manor House

This is the latest available inspection report for this service, carried out on 18th September 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

The Manor House 02/11/05

The Manor House 24/05/05

The Manor House 02/12/04

The Manor House 18/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/11/2008.

CARE HOMES FOR OLDER PEOPLE The Manor House Thurloxton Taunton Somerset TA2 8RH Lead Inspector Jane Poole Unannounced Inspection 18th September 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Manor House DS0000016162.V368496.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. The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Address Thurloxton Taunton Somerset TA2 8RH 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) 01823 413777 thurloxmanor@hotmail.com Mrs Charis Ann Cavaghan-Pack Mrs Charis Ann Cavaghan-Pack Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th September 2006 Brief Description of the Service: The Manor House is registered to provide personal care to up to four people over the age of 65. The home is very much run in a family style. Mrs Charis Cavaghan-Pack is the owner and registered manager but the home is run in partnership with her husband. Both Mr and Mrs Cavaghan-Pack live on site and both are involved in the day-to-day business of the home. The home has limited care staff hours and is therefore only suitable for service users who are reasonably independent and physically mobile. The house itself is a large Grade 2 listed building set in extensive grounds, all rooms are for single occupancy and all have en suite facilities. All areas of the home are comfortably furnished and well maintained. Fees at the home range between £495.00 and £630.00 a week. The Manor House DS0000016162.V368496.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 was an unannounced inspection, which took place over 1 day (3.5 hours) on the 9th September 2008 by Regulation Inspector Gail Richardson. There were 3 people currently residing at the home receiving personal care. A tour of the home took place and all of the bedrooms and all communal areas were seen. The inspector spoke with all 3 people using the service and 1 member of staff, the Registered Manager was not available throughout the inspection, however Mr Cavaghan-Pack who is involved with the day-to-day running of the home was available. The home has provided CSCI with a completed AQAA (Annual Quality Assurance Audit), which was completed by the Manager and gives details of all aspects of the home. As part of this inspection the inspector surveyed the opinions of people using the service and staff members and the responses from these surveys are used in the body of this report. Records relating to care including 3 care plans, 2 staff files and health and safety records were examined The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: The Manor House aims to provide a service to people with low care needs. The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 6 The home provides a statement of purpose and service user guide, which provides information for prospective people using the service. Before any new person resides at the home the manger ensures that a full assessment of needs is in place and ensures that the person can visit the home and ‘test run’ the service before deciding if it is right for them. Each person at the home has a care plan. This plan outlines the preferences of the person and an agreed plan of care is in place to support both those preferences and any specific care needs. Risks identified are assessed and plans put in place to promote choice and independence. People are supported with their healthcare needs by having the access to the appropriate healthcare professionals. Activities are not provided in a formal or group manner but people are supported to access the community and maintain contact with relatives and friends. Meals served at the home are of a high quality. The homes environment is comfortable and personally decorated to each persons tastes. People have their own lounge area and bathroom and a communal kitchen/dining area is available. Staffing levels at the home are adequate to meet the people’s needs. Recruitment is robust to ensure the protection of people living at the home. The management of the home appears to support both the people using the service and staff. Health and Safety measures are in place to promote protection and policies and procedures are in place to ensure good practice. What has improved since the last inspection? What they could do better: The care plans available at the home were appropriate for people who had minimal care needs however, the registered manager must ensure that the care plan is reflective of the persons changing needs. Also that a daily record is maintained and appropriate review and action taken to meet any changing The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 7 needs. It is further required that people using the service are included in the care planning process. The registered manager must ensure that CSCI is advised by Regulation 37 notification of any event, which may affect the health and well being of people using the service within the scope of notification. The registered manager is required to ensure that all staff receive supervision of their practice no less than 6 times each year to ensure that staff are supported to maintain a high standard of care. Further good practice recommendations have been made around monitoring and auditing medication practices, reviewing the provision of higher chairs in the communal seating area and to provide a formal accident record book. Also to ensure that a full employment history is requested to include dates of starting and leaving employment and any gaps in employment history to be investigated at interview and outcomes documented. That the declaration of the Rehabilitation of Offenders Act is included in the application form and that freestanding units be secured to the walls to prevent the e risk of injury. It is also recommended that that the home has an updated copy of the Local policy for Safeguarding Adults in Somerset to ensure that should an allegation of abuse be made staff can take the correct action to support that person. Staff training is also required in abuse awareness and it is recommended that all staff are regularly supervised.. 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. The Manor House DS0000016162.V368496.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 The Manor House DS0000016162.V368496.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): 2 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A Statement of Purpose and Service User Guide is available to provide details for any prospective person using the service. People are supported to ‘test run’ the home prior to admission. Each person has a contract which details the terms and conditions of residency. EVIDENCE: 3 Residents surveys received stated that all 3 had received a contract and all felt they had received enough information prior to admission, about the home to make an informed decision. The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 10 The inspector was able to speak to all the people using the service who stated that they had the opportunity to visit the home with their representatives before taking up permanent residence. One person told the inspector that “ I chose to come her”, another stated that “ My relative found this home for me, I think she made a good choice and I like living here ““. There have been no changes to the Statement of Purpose and Service User Guide since the last inspection. The inspector saw copies of pre admission assessments and signed contracts in people using the service individual files. The pre- admission assessments seen by the inspector show that the home looks, not just at needs, but also at lifestyle and interests. This is to ensure that the lifestyle at The Manor House matches the expectations of service users. Each person receives a further assessment after one week at the home to ensure that all areas of need are documented. The home is clear about the level of need that they are able to meet. For example there are no waking night staff and people are made aware of this during the assessment and in their terms and conditions of residency. The Manor House DS0000016162.V368496.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 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person receives personal support as they require and that has been agreed with them. Areas of physical and emotional need are assessed and a care plan is in place to ensure staff can meet those needs. These require further monitoring and documentation to ensure that a clear audit trail of changes is monitored and appropriate action taken. Systems are in place to ensure that medication is safely managed and administered; adjustments to the practice have been made to ensure that safety. EVIDENCE: The inspector viewed the care plans of all 3 people living at the home. All contained details about the person, which includes information about the needs of the person and about their personality and interests. The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 12 There are regular updates written in the care plan, however there is no daily record for each person available and people using the service also said that were not involved in review of their care plans. 4 Staff surveys said that they were given up to date information about the needs of the people they cared for. It was discussed with Mr Cavaghan-Pack that due to the low needs of people using the service a daily record was not always essential, however in the case of one person whose needs had increased recently a daily record must be undertaken and audited to ensure that changes in need where addressed and reviewed. This record would provide a clear audit trail of changes in health and the action taken to address those changes. This record should also record accidents, incidents and any visits by health professionals. People felt that their privacy and dignity were respected and spoke very highly of the staff and the care they received at the Manor House. Each person has a named nurse and people were aware of who that was. All people using the service have single rooms with sitting areas. All have personal phones. The inspector observed that post was delivered unopened and staff assisted as needed. People told us that they could get up and go to bed when they wanted and that their care needs were met as required. Mr Cavaghan-Pack has occasion to assist with moving and handling of one person and this is agreed within the persons care plan. When asked by survey of the people using the service if they received the care and support they need, 2 said always and 1 said usually and all 3 said that staff listen and act on what you say and that there were staff available when you need them. People told us that they were assisted to access the local GP, dentist and optician etc. The GP also is called to the home when needed. One person said “ If you need the dentist or doctors they take you straight away”. Another commented “ I should find it hard to find anywhere else where one had so much help” All appointments and outcomes of meetings with healthcare professionals are recorded. Two of the three people using the service self medicate and this is recorded in care plans. They have systems in place to store and administer medication, which supports and promotes their independence. One person told us “ I do my own medication, I have a system that works for me “. At the previous inspection it was identified that staff administer medication for the other person and administration practices were poor. This system was still in place at this inspection. Mr Cavaghan-Pack has a system whereby he fills a daily Dossett pack for one person, who then administers from that pack. It has The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 13 been discussed with the CSCI Regional Pharmacist and Mr Cavaghan-Pack that this practice is considered to be secondary dispensing. An alternative practice has been verbally agreed whereby Mr Cavaghan-Pack assists the person using the service to load their own Dossett box instead of doing it for them. The person using the service must sign to say that they have had the medication. This system is required to be confirmed in writing to CSCI in response to this report. The Manor House DS0000016162.V368496.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 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are supported and encouraged to partake in culturally appropriate activities. Residents are treated with dignity and respect. A healthy diet is promoted. EVIDENCE: There are no organised activities in the home and people are encouraged to pursue their own interests and hobbies for example local shops, libraries, clubs and churches. They are supported by the management of the home to access activities and on the day of inspection, visitors to the home were staying for lunch and in the afternoon Mr Cavaghan-Pack was driving a person to a local church event. People using the service stated that the home is always happy to provide transport. People said that they continued to be in control of their day-to-day lives. They are able to bring personal possessions such as furniture, pictures and ornaments with them to the home. This gives all rooms an individual homely feel. The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 15 Newspapers are delivered at breakfast time and the home access large print magazines where there is an identified need. The home is set in extensive grounds which service users have unlimited access to. The people using the service confirmed that they walk in the grounds and often sit outside. The home has a dog, which roams freely about the home and is very much enjoyed by all people using the service. All people using the service were complimentary about the quality and choice of the food. Breakfast and super are served on trays in individual rooms. One person makes their own breakfast and is supported to maintain this independence. The main meal of the day is at lunchtime and served in the kitchen/diner. The inspector observed lunch on the day of the inspection, the table was pleasantly laid and drinks, including wine, were available. There were visitors to the home and everybody ate together in a social setting. Staff sit and socialise with the people using the service during lunch. People using the service told us that the quality of the food was always good and that local produce is used where possible. There are no set menus, food is cooked according to personal likes and requests and choice is decided on the day. One person told us that “ I am very happy here- the meals are splendid”. Comments received in surveys included “ Meals are always good and well presented” and “ Our food is excellent and our likes and dislikes catered for”. Records are kept of all meals served and these show a wide variety of home cooked food. The two rooms on the ground floor have kitchen areas and the upstairs rooms share a small kitchen. It was observed that staff make sure that they always have supplies of tea, coffee and milk so that they can make drinks at any time. The Manor House DS0000016162.V368496.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 17 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People confirmed that they would raise any concerns with the staff and would be confident that they would be acted upon appropriately. Policies, procedures are in place to protect residents form abuse. Staff confirmed that they were aware of whistle blowing procedures and of their role in protecting people using the service from abuse, however staff had not received any abuse awareness training. EVIDENCE: All 3 people using the service surveys, confirmed that they knew how to make a complaint and surveys confirmed that people knew who to speak to if they were unhappy. There is a complaints policy and procedure in the policy manual for staff and people using the service have access to a complaints procedure on admission. No complaints have been recorded at the home since the last inspection and CSCI have not received any complaints about this service. The home has a whistle blowing and an abuse policy. The home does not currently have a copy of the Safeguarding Vulnerable Adults Policy for Somerset and is recommended to access this. This is required to ensure staff are familiar of action to be taken in line with local policy, should an allegation of abuse be made. All staff surveys confirmed that they would know what to do The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 17 if a concern was raised however no staff have received abuse awareness training and this is recommended to be undertaken. Recruitment procedures protect people from the risk of abuse. The Manor House DS0000016162.V368496.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 20 21 23 24 25 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manor House provides a homely and comfortable environment. It is decorated and maintained to a good standard. The facilities in the house are in keeping with the homes philosophy of supporting people to remain as independent as possible. EVIDENCE: The care home forms part of a larger building, which is also the residence of the owner/manager, with the care home being on one side of the building. Accommodation is set over two floors; there are two bedrooms on the ground floor and two on the first floor. There is a stair lift between. People are able to bring their own furniture to personalise their individual rooms. People have a key to their own apartment and the home holds an emergency access key. The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 19 Communal areas consist of a large kitchen/diner and a small lounge area. The small lounge area is recommended to have seating, which is higher and more appropriate for use, by people using the service. Currently one person is using a garden chair, as it is easier to use due to its height. Outside there are extensive grounds; the outdoor space of the home is tidy and well maintained with seating and tables. All bedrooms have en suite facilities and aids and adaptations have been put in place to assist people to maintain their independence with personal care. One person has recently had fitted an adapted bath at their own expense. En-suite bathrooms have emergency call bells. Bedrooms on the ground floor have kitchen areas where hot drinks can be made and the two bedrooms upstairs share a small upstairs kitchen. Individual risk assessments have been completed in respect of upstairs windows, hot water and hot surfaces. One person who has had an increased number of falls had an unrestricted window in their bedroom. The risk assessment had been identified as low risk. However this had not been reviewed in light of recent falls. This was discussed with Mr Cavaghan- Pack who has confirmed to CSCI that a restricting chain was fitted on the afternoon of inspection. The manager is also recommended to ensure that all freestanding units are secured to the wall to reduce the risk of injury from them. Staff maintain the home to a good hygiene standard. All 3 people using the service surveys said that the home is always clean and fresh. Food hygiene and infection control training has been provided for staff. Hazardous substances are safely locked away and COSHH sheets are available for all relevant substances. The Manor House DS0000016162.V368496.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 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a consistent staff team who know the people using the service well. There is no current training plan for staff and so no means of ensuring that mandatory updates take place. The recruitment procedures protect people using the service from the risk of harm. EVIDENCE: The home employs 3 members of staff who are responsible for all care and domestic duties. The home is clear about the level of need that they are able to meet and the home is staffed accordingly. 4 staff surveys felt that there was enough staff to meet the individual needs of people using the service. One commented that the home “ Delivers a premium service to its clients” and “ The clients needs are always met”. There are periods of the day when there are no staff on duty but the owners of the home provide support. One member of staff also lives on the premises. Overnight there are no waking night staff but people are able to contact the owners in an emergency by an alarm system, which contacts an outside agency who in turn rings the owner/manager. The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 21 4 staff surveys told us that the induction to the role covered everything. No member of staff has a National Vocational Qualification in care although one is a trained nurse. There is no training programme for staff but there is evidence in the recruitment files and 3 staff surveys that some mandatory training takes place. It is recommended that a staff-training matrix be formulated to ensure that all training updates are met with particular reference to fire training and moving and handling. The staff member spoken to was able to demonstrate a good knowledge of people using the service and their individual needs. They appeared confident and competent in their role. Staff surveys asked if staff pass information about people using the service between staff, 2 said always and 1 said usually. People using the service confirmed that staff are very kind and caring. One recruitment file was examined for the only staff member to have commenced employment since the last inspection. The recruitment details were mostly in place. However, the application form did not contain dates of the previous employment history and therefore any gaps could not be identified and explored. The manager is recommended to ensure that all prospective staff complete a full 10-year employment history and any gaps investigated at interview and documented. The Application form also does not contain the Declaration under the Rehabilitation of Offenders Act, which would make clear to all prospective staff that previous offences, which may otherwise be considered spent, must be declared. This is required to be added to the application form. The Manor House DS0000016162.V368496.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 33 36 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well organised and people using the service views are sought and play an important part in the development of daily life. The management of accident reporting and reporting of incidents to CSCI does not meet the standard. The health, safety and welfare of residents is promoted and protected. EVIDENCE: The registered manager of the home is Mrs Charis Cavaghan-Pack. The home is very much run as a partnership between Mrs Cavaghan- Pack and her husband. Neither have a formal qualification in care or management but between them they have many years experience of working with older people. The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 23 The manager does not as a financial appointee or power of attorney for any service user. There are no formal quality assurance measures in the place but people using the service stated that the manager continually asks for comments about the service provided. People stated that they were very comfortable to voice their opinions and make suggestions about the running of the home. There is no training plan for staff and so we are not able to review if updates to mandatory training are in place. Supervision of staff is not in place and is recommended to be initiated to support staff with their training needs. There is a record of accidents in a small ring bound notebook. The manager is recommended to purchase a health and safety accident record, this will enable each accident to be recorded separately and would include a review of outcomes and any further action to be taken. The home is required to inform CSCI by Regulation 37 notifications of any event, which adversely affects the well being of a person using the service or staff member. No notifications have been received since August 2007. Accident records indicate a fall took place, which required medical intervention, and CSCI should have been notified. The manager is required to ensure that all outstanding notifications are forwarded to CSCI. Mr Cavaghan-Pack carries out monthly safety checks in the home. These include smoke detector checks and water temperature checks. The records demonstarte that appropriate checks are carried out on electrical equipment, and that household eqipment is regularly serviced and well maintained. The manager is recommended to ensure that all freestanding units are secured to the wall to reduce the risk of injury from them. The Manor House DS0000016162.V368496.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 X 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 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 3 18 2 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 1 X 3 The Manor House DS0000016162.V368496.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. 1. Standard OP7 Regulation 12 15(2)(b) Requirement The registered manager must ensure that the care plan is reflective of the persons changing needs. That a daily record is maintained and appropriate review and action taken to meet any changing needs. That people using the service are included in the care planning process. The registered manager must 01/12/08 ensure that all staff have received abuse awareness training. The registered manager must 01/11/08 ensure that CSCI is advised by Regulation 37 notification of any event, which may affect the health and well being of people using the service within the scope of notification. Timescale for action 01/11/08 2. OP18 12 18 (1)(a) 37 3. OP33 The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 26 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 The registered manager is recommended to ensure that updated medication practices are regularly reviewed and audited to ensure that secondary dispensing does not occur. The registered manager recommended to ensure that the home has an updated copy of the Local policy for Safeguarding Adults in Somerset The registered manager is recommended to review the seating provision in the communal area to ensure that chairs of an appropriate height to meet people using the service’s needs are available. The registered manager is recommended to undertake a staff-training matrix to ensure that all updates in training requirements are evidenced and actioned. The registered manager is strongly recommended to ensure that a full employment history is requested to include dates of starting and leaving employment Any gaps in employment history should be investigated at interview and outcomes documented. The registered manager is recommended to include within the application form a full explanation of the Rehabilitation of Offenders declaration. The registered manager is recommended to purchase a formalised accident-recording book and ensure that all accidents are recorded in full with outcomes and review recorded. The registered manager is recommended to ensure that all staff receives supervision no less than 6 times per year. The registered manager is recommended to ensure that all freestanding units including wardrobes and storage units are made secure to the wall to prevent the risk of accidents. 2. 3. OP18 OP19 4. 5. OP28 OP29 6. OP29 7. OP33 8 9. OP36 OP38 The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 The Manor House DS0000016162.V368496.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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