Inspection on 27/09/07 for Antron Manor Care Home

This inspection was carried out on 27th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Antron Manor Care Home 07/11/06

Antron Manor Care Home 01/11/05

Antron Manor Care Home 17/05/05

Antron Manor Care Home 07/12/04

Antron Manor Care Home 22/07/04

Antron Manor Care Home 11/06/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Antron Manor Care Home Antron Hill Mabe Burnthouse Penryn Cornwall TR10 9HH Lead Inspector Diana Penrose Unannounced Inspection 27th September 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Antron Manor Care Home DS0000032603.V350888.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. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Antron Manor Care Home Address Antron Hill Mabe Burnthouse Penryn Cornwall TR10 9HH 01326 376570 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered provider(if applicable) Type of registration No. of places registered (if applicable) ROGERSWSL@AOL.COM Mr Kenneth Barrie Rogers Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: Antron Manor is situated on the edge of the village of Mabe. The home consists of an older two-storey building with a ground floor modern extension. The home is set in extensive mature landscaped grounds. The grounds can be used by the people using the service, and are partly accessible for wheelchair users. The home is registered to provide residential accommodation and personal care to a maximum of 16 older people. All bedrooms, with two exceptions, are single with en suite toilets and hand basins. The two exceptions have a toilet and washing facilities very nearby. There are five communal rooms that are used for different purposes and activities. Information about the home is available in the form of a residents’ guide, which is available in the home and can be supplied to enquirers on request. A copy of most recent inspection report is also available in the home. Fees range from £360 to £420 per week; the registered provider supplied this information to us during this inspection. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited Antron Manor Care Home on the 27 September 2007 and spent eight hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. All of the key standards were inspected. On the day of inspection 16 residents were living in the home. The methods used to undertake the inspection were to meet with a number of residents, staff and the registered provider to gain their views on the services offered by Antron Manor Care Home. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. Because the registered provider has failed to address some of the regulatory issues discussed at the last inspection requirements have been notified in this report. The registered provider said that fulfilling the roles of provider and manager can be difficult and conflicting at times. Residents expressed satisfaction with the care and services provided at the home. Overall the home is providing an adequate quality of service for the residents placed there in a relaxed friendly environment. The AQAA document had not been received prior to this inspection as it was sent out late from CSCI. What the service does well: Antron Manor provides a warm, comfortable, homely environment for the people using the service. The home is clean and there are no offensive odours. Maintenance is ongoing to ensure the premises are safe and a gardener is employed to keep the grounds attractive and safe for the people who access them. Prospective residents are assessed prior to admission to the home and they are invited, along with their family, to visit the home to meet staff and other residents. The people using the service have individual care plans that they agree and sign. A brief history of their life is included to help staff understand them as individuals and appreciate their preferences. The plans are reviewed monthly with changes recorded. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 6 The people using the service are encouraged to be independent and live their lives as they wish. Comments from residents include “It’s free and easy here”. “We do as we like, it’s our life” “There is plenty to do”. Visitors are welcome and residents can go out when they wish. Organised activities take place and entertainers come to the home. The owner has purchased a minibus to take people out. Residents help in the garden if they wish and have grown vegetables in the greenhouse over the summer months. There is a nutritious menu with fresh fruit and vegetables included. Drinks and snacks are available between mealtimes. There is a suitable complaints policy in the home and there have been no complaints. Thank you letters and cards are kept. What has improved since the last inspection? What they could do better: Regulatory issues were discussed during the last inspection and the registered provider agreed to tackle them. These along with two recommendations from the last inspection have not been addressed. The care plans still need more detail to fully inform and direct staff in the care to be provided. Care plans are reviewed on a monthly basis and changes are recorded on the review sheets. The registered provider agreed to ensure that changes are recorded in the actual care plan as this makes it easier for staff to see the changes made rather than look through several review sheets. It was evident from the records and talking to staff that some of the people using the service are at risk of falling. The registered provider must introduce a suitable written risk assessment for these people and this was discussed with him. All care staff must receive basic medicines training; Mr Rogers agreed to provide this and to include it in the induction programme for new care staff. Handwritten instructions on the medication administration records must be witnessed and signed by two members of staff. Instructions on the medicine charts should be written in ink, not pencil. There is some evidence of social activities in the daily records however it is recommended that each resident has a separate sheet in their care file for Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 7 recording social and religious activities so that it is clear that each person is having a social life. The registered provider had agreed to do this at the last inspection. Training for staff must be addressed and the following included: • Abuse and protection training • Infection control training • Health and safety training • Basic medicine awareness training • Training relevant to the client group, for example dementia and stroke training Mr Rogers said some staff work very few hours as they work elsewhere and receive statutory training there. He said he would try and obtain copies of their certificates of training for the files. He must be satisfied that any training they receive is suitable and relevant to Antron Manor. Evidence of the content of this training must be held on file. Record keeping in the home must be reviewed to ensure that appropriate records are kept according to legislation. They must all be kept up to date and dated and signed appropriately. They must also be available for inspection by relevant authorities. For example: • Training records • Fire records • Recruitment records • Photographs of both residents and staff must be kept • Resident’s money • Accident records • Kitchen cleaning records Receipts must be kept for all items and services purchased for residents, with their money held by the registered provider. Effective quality assurance and monitoring systems must be introduced with evidence of planning, reviews and actions taken. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 8 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. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 9 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 Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 10 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 (6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide appropriate care. EVIDENCE: Evidence was provided in the form of documentation, records, talking with the people using the service, staff and registered manager. Prospective residents complete an application form for consideration to be placed on the home’s waiting list. The registered provider said that prospective residents and their family are encouraged to visit the home to have a look around. The registered provider undertakes an assessment of the prospective resident’s needs during this visit or goes out to assess them; in their home or in hospital for example. Assessments inspected were satisfactory. Discharge information from hospital is obtained where appropriate. Antron Manor Care Home DS0000032603.V350888.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. Individual care plans are generated for each resident that reasonably inform and direct staff in the care provision, further detail would be beneficial. Residents have access to health care services as necessary to ensure their assessed needs are met. There are systems and policies in place for dealing with resident’s medicines extra vigilance with handwritten instructions on the charts is required to assure residents safety. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, case tracking and talking with the people using the service, staff and registered manager. Each person accommodated has a written care plan that is agreed and signed by the resident. There could still be more detail to fully inform and direct staff in the care to be provided. Life histories are included and are informative. Care plans are reviewed on a monthly basis and changes are recorded on the review sheets, the registered provider agreed to ensure that changes are recorded in Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 12 the actual care plan. There were few risk assessments included in the care files, the registered provider said this is because the residents are quite independent. It was evident from the records and talking to staff that some of the people using the service are at risk of falling. The registered provider must introduce a suitable written risk assessment for these people and this was discussed with him. He said he would do this for all of the people using the service. Day and night records are maintained and are informative. There must be a photograph of the resident in their file; some had not been included. There are records of visits by doctors and other healthcare professionals. Residents are weighed regularly according to their individual requirements. There is suitable equipment for moving and handling. A monitored dose system is in place for medications. There is a medicines policy and a homely remedies policy, the approved list has been signed by the GP. One carer is responsible for overseeing the medicine system. Care staff who administer medicines receive training in the safe handling of medicines. All care staff must receive basic medicines training and this was discussed with the registered provider. He agreed to provide this and to include it in the induction programme for new care staff. The pharmacist reviews resident’s medication regularly and provides training for staff; there is a record of her visits. Some residents administer their own medicines and sign to agree to this. The receipt, administration and disposal records are up to date. Handwritten instructions on the medication administration records must be witnessed and signed by two members of staff; this was discussed at the last inspection. The registered provider said he would address this with staff, it is noted that some of the instructions have been written by the pharmacy staff. Some items prescribed had been crossed through because they are no longer required and have not been supplied, staff are advised to state that they are no longer in use and to sign the chart. Staff were writing instructions on the charts in pencil and rubbing out and changing them if required. The registered provider has informed us since this inspection that this is no longer the case; recordings are now in ink. Controlled drugs are stored and recorded appropriately. Residents’ privacy was upheld during the inspection. Residents said they are treated with respect and their privacy is upheld at all times. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 13 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. The home provides a range of activities and aims to offer a lifestyle that meets individual residents needs. Links with family and friends are very good and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are well catered for with a varied selection of food available that aims to meet their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with the people using the service, staff and registered manager. Activities and entertainment are on offer and posters are displayed to inform the people using the service. Residents said that activities include musical entertainment, bingo, games, mobile clothes shop and armchair exercises with a physiotherapist. They said the mobile library comes to the home each month, a vicar provides Holy Communion each month and the Salvation Army visit and they all sing along. They also said that the registered provider has bought a minibus to take them out and they have been into Falmouth. One resident said she had won a prize on the bingo. Another resident was outside working in the Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 14 garden, she said they have grown tomatoes and peppers in the greenhouse this summer and they were lovely. She said she goes out to buy plants for the garden. The art classes seem to be popular and paper mache plates were seen drying out on a radiator. There is some evidence in the daily records that activities take place but it is difficult to find, it is recommended that each resident has a separate sheet in their care file for recording social and religious activities. The registered provider had agreed to do this at the last inspection. There is a record of visitors to the home and residents said they could receive visitors in private and at any time. Some said they go out with family and friends when they wish. Residents said they decide what to do each day, they choose when to get up and go to bed. Two residents said, “It’s free and easy here”. Others said, “We do as we like, it’s our life” “There is plenty to do” and “I am very busy, I have to say when I want time to myself!” One resident has her cat with her in the home which makes her very happy. Most residents manage their own money and they all have their own possessions around them including items of furniture. There is a nutritious menu that spans three weeks and fresh fruit and vegetables are included. It is a set menu but residents said they could have something different if they did not like what was on offer. Records are maintained and it is evident that some people have alternatives to the menu. Residents said the food is good and they enjoyed the lunchtime meal. Residents comments include “The food is excellent”, “The food is very good”, “There is a good basic lunchtime meal, the teatime meal is suitable but not so good”, and “The food is adequate for our needs”. Staff said that assistance is given with mealtimes if needed. There was special cutlery and a plate guard used by one resident. Refreshments were available throughout the inspection. Residents said they have a cake made for them on their birthday and they have a sherry on special occasions. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents. All staff in the home must have appropriate training to ensure that the people using the service are safeguarded from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation, talking with the people using the service, staff and registered provider. There is a suitable complaints policy in the home. There have been no complaints. Thank you letters and cards are kept. The home has an adult protection policy and staff said they were aware of this, although they said they had not received training in this area. The registered provider has attended the Adult Social Care alerters training and has a copy of the local authority procedures. He has a pack and a training DVD and said he intends to train staff in house. He said this at the last inspection and must now ensure the training is carried out. The registered provider needs to ensure that the contact details for the Commission are up to date in the policies, he said he would do this. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 16 Residents said there are no barriers to raising concerns with the staff. Staff said they could talk to the registered provider if they have any concerns as he is always in the home or contactable by telephone. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 17 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 and grounds are well maintained providing a safe environment for residents, staff and visitors. The home is clean with no unpleasant odours making it a pleasant place for residents to live in. EVIDENCE: Evidence was provided in the form of a tour of the building, talking with the people using the service, staff and registered provider. The home is warm, comfortable and homely. It is well ventilated and there is domestic style lighting. There is an ongoing maintenance programme. It is well furbished and well decorated throughout. All bedrooms have been refurbished. The grounds are tidy and there is plenty of garden seating, the gardener was working in the grounds during the inspection. Several residents said they walk out in the grounds and all spoken with said they are happy with their rooms and the facilities provided. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 18 The home is very clean and free from offensive odours. The laundry facilities are suitable with one washer and one drier. Residents said the laundry system works well. Suitable hand washing facilities are provided for staff along with protective clothing however there is no evidence that infection control training takes place. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels meet the needs of residents and staff are motivated to provide a high standard of care. Residents are in safe hands and they benefit from the 61.5 of care staff trained to NVQ level 2 in care, or equivalent. Recruitment practice has not always been robust however there have been no new recruits to check on recent practice. The registered provider is aware of the regulations. The home provides some training for staff to help them be more competent in their roles; there needs to be more training in respect of the client group and attention to records will give a better audit trail. Statutory training must be up to date and accurate records maintained. EVIDENCE: Evidence was provided in the form of documentation, records, observation, talking with the people using the service, staff and registered provider There is a set staffing rota that ensures there are two care staff on duty at all times. At night there is one awake and one sleeping. There are no overseas staff employed. Care staff take turns to cook the meals and there are separate cleaning staff. Staff said the system works well. Comments from the people using the service include “There are enough staff here”, “Staff are really good, very patient and they help us all”, “The staff are so caring”, “The staff are lovely. You won’t find a better place, it’s wonderful here”. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 20 All care staff are encouraged to undertake NVQ training. 61.5 of care staff have an NVQ at level 2 or 3. The registered provider said there have been no new recruits since the last inspection; some have worked at the home for several years. Four personnel files were inspected. Some documentation had been obtained after people had commenced work, for example CRB, POVA checks and references. The registered provider said he is now aware that new staff cannot start work without a satisfactory POVA check and they have to be fully supervised until a satisfactory CRB disclosure has been received. He is also aware that two satisfactory references have to be obtained prior to employment. The paperwork for any new recruits will be examined at future inspections to ensure the registered provider is complying with the law. There must be a photograph of each member of staff on file. Some certificates of training are held. There is an equal opportunities policy. The registered provider said that staff receive an induction to the home and a checklist is signed. There was some evidence of induction in the files. Staff have not received adult protection training. The registered provider said he did dementia training last year and conveyed this to the staff but there was no evidence to support this. There is some past evidence of staff attending external courses but nothing recent. Staff must ensure they are up to date on current issues relevant to the client group accommodated and there must be evidence to support this in the home. Staff were positive about the training they have received but it seemed as though it was just something they have to do. There is evidence that statutory training takes place although the records show that not all staff have attended according to the law. The fire drill records were up to date and fire training audits have been done. Infection control training must be included in the induction programme with annual updates for all staff. The registered provider said that some infection control is included with the food hygiene training but agreed to provide training in house. The registered provider should also obtain a copy of the documents ‘Infection control guidelines for care homes’ and ‘Essential steps to safe clean care’. The registered provider said that health and safety training is not done formally, food hygiene training is due next year and first aid training is coming up soon. He said some staff work very few hours as they work elsewhere and receive statutory training there. He said he would try and obtain copies of their certificates of training for the files. He must be satisfied that any training they receive is suitable and relevant to Antron Manor. Evidence of the content of this training must be held on file. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 21 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, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Provider is a person of good character and fit to run the home. The home is run in the best interest of the residents and they will benefit when the Quality Assurance systems are improved. There is a suitable system in the home for dealing with residents’ money that ensures that the residents’ financial interests are safeguarded although further attention is required to signing the records. Appropriate up to date records must be kept and available for inspection by relevant authorities. Safety checks of equipment are undertaken to ensure the health safety and welfare of residents and staff. EVIDENCE: Evidence was provided in the form of documentation, records, talking with the people using the service, staff and registered provider. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 22 The registered provider has the skills, knowledge and experience to manage the home. He has an HNC in Health and Social Care and has achieved the Registered Managers Award. He said he attends statutory training in the home with the staff and external courses when appropriate. He also said he attends various seminars in respect of care of the elderly and keeps up to date with current medical issues by reading relevant magazines and using the Internet. There must be evidence kept in the home to support any training undertaken by the registered provider. Residents, visitors and staff said the home is very well run and the registered provider is present in the home most days. Comments from the people using the service include, “The boss is a gentleman”, “I see the owner sometimes”, and “I see Ken every day”. Comments from staff include, “Ken is lovely to work for”, “Ken is very fair”, and “Ken works very hard and is here in the home nearly every day”. Quality assurance surveys are undertaken annually with the people using the service or their family, the annual survey is due to be done. Those inspected from previous surveys were positive. The registered provider said the pharmacist audits the medicines regularly. He said he informally audits the environment but no other audits take place. There are no staff meetings and there has only been one residents meeting which the registered provider said was not very helpful. He said both residents and staff are consulted all of the time and things change as a result of this. Staff said they speak to the registered provider every day and can air their views. People using the service said they do talk to the owner when he is in the home, some said they would appreciate meetings with other residents and staff. The registered provider said he will use his CSCI self-assessment document (Annual Quality Assurance Assessment (AQAA)) as part of his quality assurance system and he has purchased a quality assurance pack but has not used it yet. Effective quality assurance and monitoring systems must be introduced with evidence of planning, reviews and actions taken. Thirteen people control their own money and they have a lockable cabinet in their room. The registered provider holds money for three residents, he said the system works well and the money checked was correct. The registered provider must sign the records and periodically get them checked and signed by another member of staff. He agreed to do this at the last inspection. There were some receipts for chiropody but none for hairdressing; receipts must be kept for all purchases and services. Record keeping has been mentioned throughout this report and not all records have been kept up to date. Record keeping in the home must be reviewed to ensure that appropriate records are kept according to legislation. They must all be kept up to date and dated and signed appropriately. The registered provider said he tries to ensure that working practices are safe. There are health and safety policies, procedures and risk assessments for the home. There is a file for fire safety procedures and checks but some of the Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 23 records shown had not been kept up to date since June 2006 and some did not state the year. The fire drill records were up to date and fire training audits have been done. The person responsible for the fire checks and records was not on duty. The registered provider has since explained that he had not found the correct records. The records must be kept up to date and available at all times for inspection by CSCI and the fire authority. Statutory training must adhere to the law and the records must be kept up to date. Relevant service checks are up to date and maintenance takes place as required. Accident reports were not torn out of the accident book so did not comply with data protection requirements. The registered provider was aware and agreed to rectify this. The home has very few accidents, one or two a month on average. The recommendations of the environmental health officer’s report are being addressed. The cleaning rotas in the kitchen have not been signed as done and the food safety manual has not been completed. This must be addressed. Antron Manor Care Home DS0000032603.V350888.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Antron Manor Care Home DS0000032603.V350888.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 13 (4) Requirement The registered provider must introduce a suitable written risk assessment for those people at risk of falling. This risk assessment and action to be taken must be included in the care plan. • Handwritten instructions on the medication administration records must be witnessed and signed by two members of staff. • Instructions on the medicine charts must be written in ink The registered persons must ensure that the persons employed to work at the care home receive, training appropriate to the work they are to perform including structured induction training. This includes training: • Required by regulation such as fire training, first aid, food hygiene, infection control, health and safety and moving and handling. • Basic medication training • Abuse and protection training • Training in respect of the DS0000032603.V350888.R01.S.doc Timescale for action 28/11/07 2 OP9 13 (2) 27/09/07 3 OP30 18 (1) (c) 29/02/08 Antron Manor Care Home Version 5.2 Page 26 client group accommodated 4 OP33 24 (1) Effective quality assurance and monitoring systems must be introduced with evidence of planning, reviews and actions taken. 29/02/08 5 OP37 17 Record keeping in the home 29/02/08 must be reviewed to ensure that all records required by legislation are kept. All records must be appropriately dated, signed and available for inspection. For example: • Training records • Fire records • Recruitment records • Photographs of both residents and staff must be kept • Resident’s money • Accident records • Kitchen cleaning records 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 2 3 Refer to Standard OP12 OP18 OP38 Good Practice Recommendations Each resident should have a separate sheet in his or her care file for recording social and religious activities. All staff should attend regular adult protection training The registered provider should also obtain a copy of the documents ‘Infection control guidelines for care homes’ and ‘Essential steps to safe clean care’. Antron Manor Care Home DS0000032603.V350888.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Antron Manor Care Home DS0000032603.V350888.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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