Inspection on 21/08/08 for 9 Manor Road

This inspection was carried out on 21st August 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

9 Manor Road 23/08/06

9 Manor Road 21/11/05

9 Manor Road 06/05/05

9 Manor Road 28/02/05

9 Manor Road 15/01/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 12/11/2008.

CARE HOME ADULTS 18-65 9 Manor Road 9 Manor Road Leamington Spa Warwickshire CV32 7RJ Lead Inspector Julie McGarry Unannounced Inspection 21st August 2008 09:00 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 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 9 Manor Road DS0000004480.V369527.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 Adults 18-65. 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. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 9 Manor Road Address 9 Manor Road Leamington Spa Warwickshire CV32 7RJ 01926 832552 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) Eden Place Limited Richard Mark Bloomer Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Richard Bloomer (Registered Manager) must obtain his Registered Managers Award qualification by 1 January 2007. 23rd August 2006 Date of last inspection Brief Description of the Service: 9 Manor Road is part of the Eden Place group of homes. It is a mid-terraced property approximately two miles from Leamington Spa town centre. The home has three bedrooms on the first floor and a lounge, dining room and kitchen on the ground floor. The bathroom is also on the ground floor to the rear of the kitchen. The house accommodates up to three persons in single room accommodation. The communal space is shared. There is a back garden, leading to a rear gated entry. The home offers accommodation to up to three persons with mental health problems. The service is designed for people that are self-caring in meeting their physical needs and require minimum support to maintain their mental health. Information about the service is available in the home’s ‘Statement of Purpose’, which is available in the home. The residents receive a minimal amount of support from staff, which provide house keeping, cooking and domestic duties but have daily access to qualified mental health nurses from Eden Place Nursing Home, which is close by (approximately 50 yards) and within a few minutes walking distance for the residents. Range of fees: £456 per week, this is subject to change. Additional charges are made for hairdressing, personal sundries such as toiletries and newspapers, and private chiropody if required. 9 Manor Road DS0000004480.V369527.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 1 star. This means the people who use this service experience adequate quality outcomes. This Key Inspection was unannounced; it was undertaken over one day on the 21st August 2008. This inspection was carried out to establish the outcomes for people living in the home, and to confirm whether they are protected from harm. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff, people living in the home and the manager were spoken with. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. This report uses information and evidence gathered during the key inspection process, which involves a visit to the home and looking at a range of information. This includes the service history for the home and inspection activity, notifications made by the home, information shared from other agencies and the general public and a number of case files. The manager supplied us with an AQAA (Annual Quality Assurance Assessment) in August 2008. Information from this has been used to make judgements about the service, and have been included in this report. On the day of the inspection, two of the three people who live at this home were on holiday. The inspector spoke with one person on the day of the inspection and a second person on return from their holiday. The manager was present throughout the inspection. The inspector visited Eden Place in the afternoon of the inspection to examine finances and medication management. Policies, procedures and care records were examined. Staff records, environmental checks and risk assessments were also read. During the inspection, the care of all three people who live in the home was examined in detail. This included, reading assessments, care plans, and other documentation. This is part of a process known as ‘case tracking’. Where evidence is matched to outcomes for the people who live in the home. What the service does well: Manor Road is well furnished and homely which means that people have a comfortable place to live. Bedrooms were decorated and furnished to a good standard; they contained personal possessions, photographs and other effects. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 6 People are supported to gain access to advice from health professionals where they need it so their health needs can be met. The home has both a complaints policy and an adult protection policy in place. At the time of this inspection we had received no complaints and there have been no safeguarding matters since the last inspection. The home has a good system in place with regard to the appointment of staff. Records seen show that references are always obtained, and staff are not appointed prior to safety checks being undertaken. Staff working at the home have achieved NVQ’s (National Vocational Qualifications) in care. People are supported to keep in touch with their families and friends so that they do not lose relationships that are important to them. What has improved since the last inspection? What they could do better: There are gaps in people’s care plan and risk assessments that need to be updated. In particular there is a need to ensure that the information following the reviews of care plans are kept with the care plan so staff are aware of any changes made. Risk assessments must be completed based on residents’ individual needs and capabilities and reviewed to ensure risks are managed and residents are safeguarded. The home needs to ensure that all medication is appropriately stored in the home. The manager needs to ensure that regular audits are carried out to ensure all medication is accounted for. The home needs to continue to offer training to all staff. This should include Safeguarding and Whistle Blowing. This will ensure that staff take the appropriate action if there are any allegations or suspicion of abuse, and will equip staff to meet the needs of people living in the home whilst carrying out their work safely. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 7 Consideration needs to be made with regard to the management of finances to ensure all monies are auditable and people’s independence is promoted. The management of the home must improve, and develop effective ways of assessing and monitoring the quality of the service. This is so that shortfalls are identified, are improved on and the quality of the service is kept under constant review. 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. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to decide if the home can meet their needs. They have their needs assessed and a contract that clearly tells them about the service they will receive. EVIDENCE: The home has a Service User Guide and Statement of Purpose in place. These are detailed and lengthy documents. Both documents would benefit from being reviewed to ensure that they are accessible to those living at the home. Two files of people who live at the home looked at contained contracts for their stay there. One person living at the home had recently moved from another home within the organisation. No pre admission assessment was needed for this move as staff already had written care plans and risks assessments in place. In place of a pre admission assessment, staff should have reviewed the care plans and risks assessments of this person to ensure that the home was able to meet this persons needs. All documentation following the move should also have been updated to reflect this person’s change of address within the organisation. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 10 Before agreeing to the move to Manor Road, this person was able to visit the home and knew both the staff and people who live there. Due to the amount of time some of the residents have been living in the home, staff should not only undertake a continual reviewing process of care plans, but also a formal reassessment of needs to ensure that care plans reflect all the up to date information required. There is no evidence that people who live at the home and are funded by Adult, Health and Community Services are receiving Annual Reviews of their care. The manager needs to ensure that people living at this service are accessing all services available to them. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The outcomes for people who use this service are good and people are supported to make everyday choices so that they can exercise some control over their daily lives. EVIDENCE: Care plans of three people were examined. Some elements of these were good in providing detailed guidelines for staff in supporting residents. Further work however must be undertaken to ensure documents are completed in full and reviewed to ensure records evidence needs are current and are being appropriately managed. For example, two people are assessed as having ‘Low’ levels of needs and risks. However, staff store and manage their cigarettes and finances. There are no care plans in place to reflect the need for this type of staff support. To ensure that peoples choices and independence are 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 12 promoted, staff need to ensure that there are records in place to show that people are in agreement to this support and provide details of how the support is to be managed. Lifestyle assessments are in place, detailing people’s goals and aspiration for the future. Goals identified in these plans show their wishes and preferences about what they want to do on a daily basis and how they maintain links with their local community. One person spoken to confirmed that the goals identified in the lifestyle assessment reflects their wishes and that they are able to participate in the events recorded. There is no evidence that social services reviews are being undertaken annually. The manager has agreed to contact the local authority to make arrangements for these to happen. Two people’s records have a recent summary review of their needs; however this information is not kept with the care plans or risk assessments. This could lead to new staff not providing the appropriate care and support should needs change. Risk assessments were available for mobility, nutrition, self-neglect, social isolation, and risk to self and others. Information held in the records showed that levels of assessed risk was consistent with the six monthly reviews held with mental health professionals The home has an open visiting policy. People are encouraged to maintain links with their family, friends and local community. People living there told us their visitors are made welcome and there are no restrictions on the time of visits. The home has a minibus and there are weekly trips out. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make choices about their life style, and supported to develop life skills. Social, educational, and recreational activities meet individuals’ expectations. EVIDENCE: People spoken with were positive about their life style and said they were happy living in the home. ‘I am happy living here, I like it’ The home promotes flexible routines for the people who live there that respect their difference and individuality. People are supported to lead ordinary lives as far as possible and are involved in aspects of decision making on a day to 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 14 day basis within the home. For example, people living here can go out shopping each week to buy foods for the home, choosing what they would like to have each week for meals. They are offered choices about what to do each day. One person told us that ‘some times I like to stay here, read and listen to my music’ and ‘other times, I like to go out on trips in the minibus to different places’. One person whose faith is important to them is supported to go to church each week to practise their chosen faith. People are enabled to see their family and go out independently or in smaller groups. The home has a minibus, which is used to transport people to various community centres, coffee shops or other outings such as barge trips. One person told us that they are supported to visit their family in Spain, and plans are being looked at for another visit around Christmas time. People who live here are encouraged to access the community on a frequent basis and to use local amenities. The service has maintained the quality and variety of food since the last inspection. Two people spoken with said that they enjoyed their meals. People have the choice of joining the neighbouring home for meals, but can stay in their own home if they prefer. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records that describe individual’s health and medication needs are not always completed in detail and reviewed to describe how those needs should be met. Medication is not appropriately managed in the home and the safe administration and management could not be assured. EVIDENCE: It was evident from observation that the personal care needs of people living in the home are met. People looked cared for; they were well groomed and wore well-laundered clothes. Each person had a care plan, daily records and monitoring records. Care plans were based on information secured during the initial care needs assessment. There was evidence that care plans had been discussed and agreed with the people who live there, however they are not all regularly reviewed. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 16 As previously noted, risk assessments were available for mobility, nutrition, self neglect, social isolation, and risk to self and others. Information held in the records showed that levels of assessed risk were consistent with the six monthly reviews held with mental health professionals. One person spoken to openly discussed their mental health needs and the support they receive at Manor Road. They told us that since moving to Manor Road their mental health needs and general wellbeing had improved. This positive change in their health and wellbeing was also reflected in their review reports with mental health professionals. Access to other healthcare professionals such as the chiropodist, GP and optician were recorded in the case files of people living in the home. One person has previously been assessed as ‘borderline diabetes’. Records show that this person is able to have annual appointments to monitor for ‘retinal abnormalities’. Their care plan reflects the need for low sugar foods to be offered. Another person has high blood pressure. Their care plan states that blood pressure needs to be monitored twice weekly, records seen show that this is happening. One resident has close monitoring of blood levels due to medication. These records are well maintained and visits to specialists are organised as required. The systems for the management of medicines in the home were examined. Medicines are stored in locked cupboards within an office at Eden Place. Audits of the medication of the people involved in case tracking were undertaken and were not correct indicating that there are possible errors and medicines had been not administered as prescribed. The medication sheets (MAR) show that the number of tablets received so that they can be accounted for, and that staff are signing for the medication given out. The audit trail shows that there are possible medication errors by staff. Two medication sheets contained no details of the administration of ‘homely’ remedies such as paracetamol, despite evidence that tablets were missing from the boxes. There was an excess amount of tablets to that recorded on the MAR sheets for two people, indicating that staff are signing the sheet before people are taking the tablets. For example, one person’s medication sheet showed an excess of two tablets against that recorded on the MAR sheet. Two tablets were found lying lose in the box, this would indicate that staff signed the sheet before the person took the tablet and also indicates that the person may have refused to take their medication on two occasions. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 17 There is an amount of positive risk taking taken into consideration to promote independence. Residents are assessed and monitored to ensure the safety of self-medicating. Some residents have been assessed as requiring prompts in the form of a phone call from the home to remind them to take evening and nighttime medications. Staff when on duty also supervise that medications have been taken appropriately and residents are supplied with a secure facility in their room to safely store medicines. The recording, administration and medication management systems need to improve. This is to make sure that people receive their medication as prescribed and that there are systems in place to make sure medication is administered safely. There was no record of temperature recording. Medication must be stored below 25°C to ensure the stability of the medicines. A medicines fridge was available with daily recordings of the temperature using a maximum-minimum thermometer. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Residents feel that they are able to express their views and opinions and that they are taken seriously. Procedures in place to protect residents are robust. EVIDENCE: The home has a formal complaints policy which is accessible to people living in the home and their families. People are encouraged to raise their concerns with the manager. People living at the home would benefit from the policy being updated in line with the policy held at Eden Place to ensure a consistent approach to dealing with complaints and concerns through out the organisation. The manager said that no complaints have been received since the last inspection, but all complaints received for any of the homes in the group are recorded in a log and all complaints are investigated and reported on by the manager. We have not received any information raising complaints or concerns about this service since the last Key Inspection. People were observed to be familiar with the senior staff on duty and felt confident to make requests. This suggests residents would be confident in raising concerns with staff. One person was asked whom they would speak to should they have any complaints or concerns. They stated that ‘I have no complaints’ but were able to name staff that they would be able to speak to. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 19 Staff training records demonstrate that most of the staff had received training in recognising and responding to signs of abuse. The manager needs to ensure that all staff are trained in safeguarding policies and procedures. This extends to the housekeeper who visits the home 5 days a week. It was evident through discussion that the manager is aware of his responsibilities when he is alerted to allegations or suspicion of abuse. However the vulnerable adults and whistle blowing policies would benefit from being updated to contain the local authority details about safeguarding contacts. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, safe and comfortable environment that meets their individual needs. Some further improvements need to be made to ensure the bathroom fittings are in good working order. EVIDENCE: Improvements have been made since the last inspection to the maintenance of the house, and there are plans for further improvements to be made. The manager informed us that new flooring would be put down in the kitchen and bathroom. The manager also acknowledges that some further work needs to be done in the bathroom as the toilet is cracked and the bath comes loose. The home has met the requirement made at the last inspection, and appropriate action has been taken to improve fire safety measures within the home. As recommended at the last inspection, the home has looked at the boiler and pipes in the small bedroom, and these have been removed to ensure the safety 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 21 of the person using the room whilst creating more storage space for them. The home has also improved the security at the home by putting a secure lock on the back gate. The home was bright and tidy and no unpleasant odours were noticed. A homely feel is achieved in the communal lounge by placing chairs and furniture in a way that encourages people to interact. People living at the home are clearly involved with the choices made for replacement furniture and feel happy to raise issues about areas that they feel require further improvement. For example, one person living there spoke positively about the improvements made especially their bedroom, and made requests for further changes to their room to meet their personal preferences. One person also requested a new mattress for their bed. The manager checked the mattress and agreed that this now needed to be replaced. The manager reassured us that this would be done. People living at Manor Road have a cat, which they care for with some support from staff. The kitchen was clean and well organised. Records were kept of the fridge and freezer temperatures showing appropriate temperatures to maintain good food safety. To help maintain good infection control procedures, staff should be supplied with paper towels in the bathroom and kitchen area rather than using shared cloth towels. Laundry facilities are domestic in nature but are suitable to the needs of the people who live there, and they are supported in undertaking some laundry and cleaning duties. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A well-trained and competent team of established staff who have good understanding of each individual needs supports them. The home operates a robust system of recruiting staff for the protection of the people who live there. EVIDENCE: There are currently two members of staff who work approximately four hours per day, Monday to Friday on a rota system, but residents also have regular access to the staff at Eden Place. Whilst these are the average hours worked, the manager was able to demonstrate that this could be changed according to the needs of the residents at any one time, and that the start and end times of a shift were flexible to respond to trips, outings or appointments. People living at the home are aware which member of staff works on which day, and what systems are in place to cover leave and sickness. The two people met at the inspection spoke highly of both members of staff. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 23 Three staff files were looked at to ascertain whether recruitment policies were robust. The recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. Staff were not receiving formal supervision at the time of this inspection. The manager has informed us that this will now become standard practice for staff. A training matrix is maintained and used to record staff training and to identify any gaps in learning. Records demonstrate that staff complete an induction programme and receive mandatory training in food and hygiene, infection control, first aid, abuse awareness, fire safety and challenging behaviour. This should mean that staff are updated in safe working practice. The management should however ensure that training in safeguarding of people is extended to the housekeeper who visits the home every Monday through to Friday. Information supplied by the manager state that both members of care staff are qualified to National Vocational Qualification in Care Level 2 (NVQ level 2) or above. This is above the National Minimum Standard of 50 of staff to be qualified. This should mean that residents benefit from having their needs met by staff that are appropriately experienced and qualified. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed in a way that listens to and acts upon the views of the people who live there. EVIDENCE: The manager of the home is also the manager for Eden Place and another small home in the group. He has now been in post for over two years. The manager is a qualified nurse with experience working with people with a broad spectrum of psychiatric conditions. He continues to work towards achieving his NVQ level 4 in management. The Annual Quality Assurance Assessment (AQQA) completed by the service manager was completed to a good standard. Information provided was supported by a range of evidence, and the Annual Quality Assurance 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 25 Assessment (AQAA) fully informed us about changes the home has made and where improvements still need to be made. The management of the home must improve, and develop effective ways of assessing and monitoring the quality of the service. This is so that shortfalls are identified, are improved on and the quality of the service is kept under constant review. For example, the manager states that informal resident meetings are happening, however there are no records of the meetings detailing what was discussed or what has been agreed. The manager has agreed to make recordings of future meetings and discuss with the people who live there the best way to record their views on the service and how the quality of the service can be improved. As stated in the personal health section, regular audits of medication should be undertaken to ensure medication is accounted for and correctly stored. People living here are supported to manage their finances. Monies of all three people living there were looked at in detail. On the day of the inspection, there was an audit trail of how finances are managed at the home with statements and receipts evident. However staff keep a pool of peoples monies, and it was not possible to determine if the balance on the finance sheet for each individual could be accounted for in the pool of money. The manager needs to look at how peoples monies are managed and this needs to be reflected in peoples care plans and risk assessment plans. The home should ensure that a process is put in place that appropriately supports each individual based on their needs and not managed to the convenience of staff. Staff are not receiving regular supervision. The manager informs that this will now become standard practice. A sample of service and maintenance records was examined. This demonstrated that systems for monitoring when essential service and maintenance of equipment is due are sufficiently robust. Fire alarm systems are checked weekly; hot water outlet temperatures are recorded weekly and were noted to be within recommended limits and Annual Electrical Portable Appliance Testing has been completed. 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? 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 YA20 Standard Regulation 13 (2) Requirement Staff drug audits need to be undertaken to ensure all medications are accounted for. Appropriate action must be taken when discrepancies are found. Medication must be administered at the prescribed dosage and at correct intervals. All staff working in the home must be trained in all areas related to Safeguarding Vulnerable Adults. This will ensure that people who use the service are protected from harm and abuse. More robust management of finances must be put into place regarding residents’ money held for safekeeping. Peoples wishes related to spending need to be established. This will ensure that the financial interests of people using the service are protected. A robust quality assurance system must be put into place, DS0000004480.V369527.R01.S.doc Timescale for action 11/09/08 2 YA32 13 (6) 11/09/08 3 YA23 17 11/09/08 4 YA39 24 11/09/08 9 Manor Road Version 5.2 Page 28 and demonstrate how improvements are to be made. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 9 Manor Road DS0000004480.V369527.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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