Inspection on 06/10/08 for Arden Manor

This inspection was carried out on 6th October 2008.

CSCI found this care home to be providing an Adequate 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

Arden Manor 09/10/06

Arden Manor 11/04/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Arden Manor 67-69 Birmingham New Road Lanesfield Wolverhampton West Midlands WV4 6BP Lead Inspector Rebecca Harrison Unannounced Inspection 6th October 2008 09:45 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 Arden Manor DS0000066026.V372859.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. Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Arden Manor Address 67-69 Birmingham New Road Lanesfield Wolverhampton West Midlands WV4 6BP 01902 498820 01902 498820 ardenmanor@hotmail.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Vijay Odedra Mr Arjan Bhoja Odedra, Mrs Shanta Arjan Odedra, Jasvinder Takhar, Daljit Takhar Manager post vacant Care Home 21 Category(ies) of Dementia (21), Old age, not falling within any registration, with number other category (21) of places Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other categories (OP) 21 Dementia (DE) 21 The maximum number of service users to be accommodated is 21. 2. Date of last inspection 9th October 2006 Brief Description of the Service: Arden Manor is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for up to 21 Older People with or without dementia. The home is situated in Lanesfield within easy access to Wolverhampton City Centre and local shops and amenities. The property, which was originally built during the 1930’s, has been converted and extended. People are provided with single bedrooms and have access to a range of communal areas in addition to an enclosed garden to the rear of the property. The home makes their services known to people in a Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk At the time of the inspection the fees charged ranged from £357.00 - £420.00 per person per week however the reader may wish to obtain more up to date information direct from the care service. Arden Manor DS0000066026.V372859.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 1 star. This means the people who use this service experience adequate quality outcomes. One inspector carried out the inspection over six and a half hours. A range of evidence was used to make judgements about the service to include discussions with six people who use the service, four staff, the manager and the proprietor. The manager of another of the providers’ homes also assisted with the inspection process. We did a tour of the home, reviewed the homes quality assurance processes and observed the care experienced by people using the service. A number of records were reviewed to include complaints and protection, staff training, recruitment and health and safety records. Two people who live in the home were ‘case tracked’ this involves establishing individuals experience of living in the care home by meeting them, discussing their care with staff, looking at care files and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The provider has been requested to complete an Annual Quality Assurance Assessment (AQAA) document for us. The AQAA is a self-assessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. We completed an Annual Service Review on 25th April 2008. This did not involve a visit to the service but is a summary of new information given to us, or collected by us, since we did our last key inspection on 9th October 2006. A copy of the Review can be obtained direct from the provider. This inspection reviewed all twenty-two of the key standards for care homes for Older People. Information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. What the service does well: Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 6 The home has been successfully extended and both the management team and staff worked hard to ensure little disruption was caused to residents and visitors. People living at Arden Manor are supported by a committed team of staff who work hard to meet their individual needs and positive working relationships have been developed. People are provided with a homely place to live. Bedrooms are personalised and the home is domestic in appearance. Comments from people who us the service include: ‘These people here have saved my life, the food is lovely, I have a comfortable bed, I’m well cared for and the staff are good’ ‘The staff are just a call away, they are lovely’ ‘I’m happy living here’ What has improved since the last inspection? What they could do better: People told us that more staff are needed to deliver the service and improve outcomes for people living at Arden Manor. A review of staffing levels should be undertaken at the earliest opportunity to ensure the staffing structure is based around delivering outcomes for people using the service. At the time of our inspection the staffing levels did not meet the proposed levels agreed as part of the major variation to register an additional two places. Staffing levels should be subject to regular review and risk assessment in response to occupancy levels, service users presenting care, supervision and the support needs of the people accommodated. People living at Arden Manor cannot be fully confident that they receive the care they need because their care plans lack detail about how they prefer their care to be delivered. A new format for care planning has been developed and is Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 7 being introduced. The manager must ensure that each individual has a detailed care plan as soon as they are admitted to the home to ensure people living at Arden Manor receive their care how they prefer ensuring consistency of care. Opportunities for activities could be improved. Discussions held and observations evidenced that the home needs to further develop, in consultation with residents, a structured programme of activities and events from which they can choose. These should be appropriate to the age and needs of individuals accommodated. Where it has been identified that an individual’s behaviour can challenge, clear guidelines should be developed to ensure staff support the individual in a positive and consistent manner. Staff need to receive formal supervision at the required frequency, which is dedicated time set aside for staff to receive support and identify any training needs regarding their work. The new manager fully acknowledged the shortfalls in the service and appears committed to improvement. The manager is currently receiving additional support from a manager of one of the providers’ other homes to assist her with fulfilling her role and responsibilities. This will help to deliver effective outcomes for people using the service. 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. Arden Manor DS0000066026.V372859.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 Arden Manor DS0000066026.V372859.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): 1 and 3 (standard 6 does not apply to this service) Quality in this outcome area is good Information about the service is made available to help prospective residents make an informed choice about whether the home is able to meet their individual needs. An assessment of needs is undertaken or obtained and people are given the opportunity to visit the home to ensure the service is right for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People are provided with information about the service through the Statement of Purpose and Service User Guide. The documents have been updated to reflect the increase in registered numbers but need updating regarding the change of manager. These documents provide people with information to help them understand the services that Arden Manor provides. Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 10 The number of registered places has increased to 21. The home was fully occupied at the time of our inspection. The home has an admissions procedure in place, which is documented in the Statement of Purpose and discussions with the manager demonstrated that she had a good understanding of the procedure. Care management assessments are obtained where required and the manager stated that preadmission assessments are undertaken, as seen on the files examined. Prospective residents and their representatives are welcome to visit the home and meet with the people who use the service and staff to ensure they are satisfied with the home, prior to admission. Arden Manor DS0000066026.V372859.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 adequate The majority of people living at Arden Manor have a care plan in place however these must be completed on admission and be detailed so that staff have all the information they need to ensure people get the care they need in the way they prefer. People who use the service are not fully safeguarded by the home’s system for handling, storing and administering medication. The principles of respect, dignity and privacy are put into practice ensuring people are treated as individuals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at Arden Manor cannot be fully confident that they receive the care they need because their care plans lack detail about how they prefer their care to be delivered. For example the exact level of ‘assistance’ a person requires with personal care tasks should be clearly identified to ensure people Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 12 receive their care in a consistent manner. A care plan had yet to be developed for the person admitted to the home 12 days earlier, however the manager committed to give this priority. Guidelines had not been developed to ensure staff support another individual whose behaviours can challenge the service. A new care planning format has recently been developed and is being implemented across the service. The format is much improved and when completed should provide staff with the detailed information they need to ensure individual needs of people living at Arden Manor are met. Assessments for risk such as nutritional, falls, manual handling, behaviours, and mental health were available on the one file examined with evidence of review. Discussions held with a number of people who use the service evidence that daily routines are flexible in accordance with their individual’s preferences such as rising and retiring to bed. Records held for the people we ‘case tracked’ evidence that their health needs are monitored and kept under review and that the home arranges for health professionals to visit as required and all appointments and outcomes recorded. Medical histories were detailed in the needs assessments seen on the files we examined. The manager reported that only staff that have undertaken training in the safe handling of medicines are permitted to administer medication, which was confirmed by a member of staff we spoke with. An audit of the homes medication was undertaken by the supplying pharmacy in August 2008 and the recommendations made have been complied with. We found evidence that one person did not receive their prescribed medication on one morning in September. Managers acknowledged this shortfall and have developed a tool to audit medication on a weekly basis and committed to undertake written assessments to measure staff ongoing competence. The philosophy of care to include respecting people’s rights, privacy and dignity is documented in the homes Statement of Purpose and Service User Guide. Discussions held with some of the people using the service indicated that this is upheld. During a tour of the home the provider was seen to knock on people’s bedroom doors prior to entry. Arden Manor DS0000066026.V372859.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 adequate People living at Arden Manor are enabled to keep in contact with family and friends but may benefit from greater opportunities to develop and maintain their social and recreational interests so that they can lead their life in a chosen way. People who use the service receive a healthy, varied and balanced diet according to their assessed requirements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Needs assessments seen on the two files examined detailed people’s likes, dislikes, hobbies and interests. Personal profiles are developed and include information such as important people, former occupation and life experiences that help staff gain an overview of the person. People we spoke with told us that the home provides some activities for them to participate in if they choose to do so. During the inspection people watched television, spoke about old times with staff and some purchased sweets from an external confectionary company who visit the home once a week. Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 14 People we spoke with told us that a Halloween party has been organised and a trip to the theatre arranged. It was reported that the home has two care staff designated to organise activities in addition to their care role. An activities book is held and details the activities that people have partaken. These include watching films, board games, music, manicures, hairdressing and softball. Comments we received include: ‘I would like to go out more’ ‘We could do more’ Visitors are welcome to visit the home and are made welcome as observed during our inspection. The Service User Guide states ‘Such visits are appreciated by both service users and staff and form part of the normality of everyday living, which we aim to provide at Arden Manor’. Discussions with the cook evidenced that she is committed to providing people with a balanced diet taking into account special dietary and cultural needs. The menu was displayed on the wall in the main lounge and the meal served at lunchtime was well presented and staff were seen to make the mealtime a social and enjoyable experience. People we spoke with told us they like the food and that they are offered choice. Comments include: ‘We have lovely food here and there are lots of choices’ ‘The food is good’ ‘I really like the meals’ Arden Manor DS0000066026.V372859.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 People who use the service and their representatives are able to express their concerns and have access to a complaints procedure. Procedures are in place to safeguard people from potential abuse and staff receive training ensuring people who use the service are protected from abuse and have their legal rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People we spoke with told us they are happy with the service that they receive and said they would speak to staff if they had any concerns. The home has a complaints procedure in place and this was seen displayed in the hall and documented in the Statement of purpose and Service User Guide. We have not received any complaints since our last key inspection however we received two concerns about the way the home failed to effectively manage the outbreak of an infectious disease in December 2006 and a concern in March 2007 regarding the lack of moving and handling training, activities and recruitment checks. We asked the registered manager to investigate these concerns. The new manager was unable to locate the complaints book to evidence the outcome of the investigation however agreed to provide a new complaints book and stated that the home had not received any complaints since she commenced employment in July 2008. Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 16 The home has a copy of the local multi-agency safeguarding adult policy and procedure, which is located in the reception. No referrals under safeguarding adult procedures have been triggered since the last key inspection. It was reported that the majority of staff have received training in adult protection and certificates of attendance were seen on two staff files examined. Arden Manor DS0000066026.V372859.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 The environment has been extended and improved and provides people living at Arden Manor with a homely, clean and comfortable place to live where they feel safe and secure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People we spoke with told us that they like living at the home and are pleased with the improvements made. Staff considered the improvements have greatly benefited the residents. Improvements include an additional two ground floor single bedrooms with ensuite facility, additional lounge space, a new dining area with replacement furniture, a new sunroom/quiet lounge, and an additional shower/wet room with toilet. Bedrooms are personalised with family photos and ornaments. Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 18 People are provided with a clean home which is free from unpleasant odours. Products hazardous to health are appropriately stored however new assessments for their safe use need to be obtained. Some staff have received training in infection control procedures and were seen using the appropriate personal protective equipment throughout the inspection. An infection control audit was undertaken by Wolverhampton City Primary Care Trust in July 2008 and the home achieved an overall score of 60 . The new manager stated that many of the recommendations have since been actioned and procedures much improved as seen at the time of our inspection. Arden Manor DS0000066026.V372859.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 poor Staff work positively with the people they care for and receive some opportunities for training to equip them with the skills and knowledge to meet the individual needs of the people living at the home. The lack of robust recruitment procedures has placed people at risk of harm because the service has not secured suitability of candidates before they have commenced working at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People we spoke with told us that they are happy with the care they receive and that they are cared for well. One person stated ‘The staff are lovely, there is not one bad one’ another person said ‘The staff are very nice but we could do with extra staff to help us’ Throughout the inspection staff were accessible, good listeners and communicated well with the people using the service. The manager reported of the 15 care staff employed, 10 to her knowledge hold a nationally recognised care qualification known as NVQ at 2 or above but this needs to be confirmed. Current staffing levels were discussed with the manager, people who use the service and staff on duty. Discussions indicated that a review of staffing levels Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 20 needs to be undertaken to ensure the staffing structure is based around delivering outcomes for people using the service. On arrival to the home there were two care staff on duty in addition to the cleaner who was covering the care role for a colleague who had telephoned in sick. Current staffing levels do not meet the proposed levels agreed as part of the major variation to register an additional two places. This was fully acknowledged by the provider and the manager who committed to review this as a matter of urgency and keep levels under review based on occupancy and the assessed need of people accommodated. Staff retention is good. It was reported that one member of staff has left the service in the last twelve months in addition to the registered manager. No new care staff have been recruited however one person has been offered employment but is awaiting pre-recruitment checks to be undertaken. One domestic member of staff has been recruited in addition to the new manager who transferred from one of the providers other care homes. Recruitment procedures were reviewed and some shortfalls were identified for example one application form examined failed to contain a full employment history and although three references had been obtained, a reference had not been obtained from the previous employer. A conviction seen on a Criminal Records Bureau Check had not been declared on the person’s application form. Such shortfalls were fully acknowledged by the new manager who committed to review the homes recruitment practices immediately to ensure people are not placed at risk in the future. Without an overall staff training matrix in place it proved difficult to establish the training staff had undertaken. Individual staff training records and training certificates were available on the files sampled and staff spoken with reported that they are provided with good training opportunities. It was reported that Skills for Care induction has been sourced, first aid training has been booked and that the majority of staff have completed dementia care training. The manager agreed to complete a training matrix and an overall staff-training plan based on the training needs of her team, which will assist in future planning. Arden Manor DS0000066026.V372859.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): 31,33,35,36 and 38 Quality in this outcome area is adequate People living at Arden Manor benefit from having a management team who appear committed to meet their care needs however some systems are making people potentially vulnerable and action taken to improve processes will improve the overall quality of the service. Quality assurance requires further development to assess performance and evaluate outcomes for people using the service. The premises are not maintained or managed in a manner which ensures the safety of service users and staff. This judgement has been made using available evidence including a visit to this service. Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home is currently without a registered manager. The former deputy manager has very recently been appointed to manage the service and is in the process of completing an application for registration. The new manager fully acknowledged that much work is required to improve overall outcomes for people living and working at Arden Manor. She appears committed to improving the service and is currently being provided with additional support from a registered manager of one of the providers’ other care homes. She stated that she is due to commence the Registered Manager’s Award shortly. Managers spoke positively about the support they receive from one of the providers, Mr Takhar, who visited the home during the inspection and of his commitment to the service. The previous registered manager distributed satisfaction questionnaires to people living and working at the home in April 2008 and people were asked to comment on areas to include personal care, catering, daily living, premises and management. Comments seen in the completed surveys were generally positive overall and include the following comments: ‘We are pleased with the care mum is receiving’ ‘When a light bulb goes in my room, I sometimes have to wait weeks for it to be replaced’ ‘I would like to go out more often and enjoy more entertainment’ ‘It’s all very good’ The home has recently received two compliments from relatives thanking staff for the care provided. Visits and reports required under Regulation 26 are undertaken at the required frequency. However reports do not reflect shortfalls within the service as highlighted throughout this report. Neither do they focus on outcomes for people and how the service could be developed in the best interests of people living at the home. Staff receive formal supervision but not at the required frequency. The new manager acknowledged the need to improve and provide structured staff supervision which is dedicated time for staff to receive support regarding all aspects of their practice, the philosophy of care and career development needs. Arrangements for the management of people’s finances were discussed with managers. It was reported that the majority of finances are managed by Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 23 residents’ relatives who provide the home with money for chiropody, hairdressing, newspapers and toiletries etc. Records were available for the finances held and two signatures and receipts are obtained for all transactions. An agreement for money held on behalf of the individual should be obtained and how this is managed should be clearly documented in the peoples care records. The manager undertakes audits and it was reported that Head office are informed monthly of all monies held in the homes safe for the purposes of insurance. Health and safety procedures need to improve to provide greater protection for the people living at the home. Certificates for the servicing of equipment are maintained however not all safety checks are undertaken at the required frequency for example testing of the fire and emergency lighting. Risk assessments for safe working practices were not readily available and the practice of ‘propping open’ doors requires review. The development of an overall staff training matrix will assist the new manager with identifying any shortfalls in mandatory training for example manual handling, first aid, fire etc to ensure staff are fully equipped with the skills to carry out their roles and for the protection of people living at the home. A number of requirements made by the Fire and Environmental Health Officers remain outstanding. Arden Manor DS0000066026.V372859.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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 2 x 2 Arden Manor DS0000066026.V372859.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 OP27 Regulation 18(1)(a) (c) 19 Schedule 2 Requirement There must be sufficient staff on duty at all times to ensure the health and welfare of people using the service All pre-recruitment checks must be undertaken on new employees before they commence direct work. This will ensure people living at Arden Manor are protected by the home’s recruitment policy and practice and safeguarded from harm. Timescale for action 31/10/08 2 OP29 31/10/08 Arden Manor DS0000066026.V372859.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 OP7 Good Practice Recommendations Care plans should be more detailed and describe how all people’s needs in respect of health and welfare are to be met. This will support staff to provide care in such a way as to ensure all service users needs are met. Medication should be regularly audited to ensure people receive their prescribed medication for their health and wellbeing and competency assessments undertaken for staff responsible for managing medication. A staff-training matrix should be developed and an individual training and development assessment undertaken with staff which identifies their training needs and actual training undertaken. Health and safety checks should be undertaken at the required frequency and requirements made by Fire and Environment Health Departments complied with to ensure people living at Arden Manor are not placed at risk of harm. 2 OP9 3 OP30 4 OP38 Arden Manor DS0000066026.V372859.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Arden Manor DS0000066026.V372859.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. 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