Inspection on 24/08/06 for Arran Manor

This inspection was carried out on 24th August 2006.

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

Arran Manor 25/06/08

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Arran Manor 55 Westmoreland Avenue Hornchurch Essex RM11 2EJ Lead Inspector Diane Roberts Key Unannounced Inspection 24th August 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Arran Manor DS0000065865.V309047.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. Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Arran Manor Address 55 Westmoreland Avenue Hornchurch Essex RM11 2EJ 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) 01708 452 765 01708 452 804 Ms Beverley Holmes Ms Beverley Holmes Care Home 22 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (22) of places Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ms Beverley Anne Holmes will be registered as the manager for six months, effective from the date of registration (2 December 2005) of Ms Beverley Anne Holmes as the registered person. Before the end of the six-month period an application must be received by the Commission for the registration of a new manager. New Service 2. Date of last inspection Brief Description of the Service: Arran Manor is a large converted house set in an attractive residential area. The home has a small car park and it is within walking distance of local bus routes. The home has a good-sized private garden to the rear with a patio. The home primarily provides care for older people, with a variation to registration to allow 5 people with dementia to live at the home. Not all these beds are occupied at the current time. The home does not provide nursing care and does not take people who are wheelchair dependant. The current scale of charges is from £450.00 to £520.00 per week. There are additional costs for items such as hairdressing, toiletries, chiropody and newspapers. Information is made available to prospective service users via a Service Users Guide, which is available prior to admission and throughout the home, with copies in every room. Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over seven hours and was carried out as part of the annual inspection programme for this home. The proprietor/registered manager was available during the inspection. The proprietor plans to stand down as manager, when the deputy is successful with her registration application. This had been submitted to the CSCI and the deputy was waiting for her fit person interview. This was the first inspection for this home with new owners. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. Three residents, three visitors, and three staff were spoken to during the inspection. Resident comment cards from the CSCI were not used on this occasion as the home had only just completed their satisfaction questionnaires. On review, these were seen as acceptable to use. 10 questionnaires were used and comments from these were taken into account when writing the report. What the service does well: What has improved since the last inspection? This is the first inspection with the new owners and therefore no previous inspection report to take into account. However, it is clear that the new owner has made significant improvements to both the care and facilities provided at the home and both residents and relatives confirmed this. Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 7 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 Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive information is made available and continues to be developed. Prospective residents are properly assessed prior to admission to the home. EVIDENCE: The home has both a Statement of Purpose and Services Users Guide in place, which meet the required standards. The Service Users Guide is comprehensive and carries a lot of extra information in small print. The management team may wish to give some consideration to this at the next review of this document in light of the resident group in the home. Service User Guides were seen in every bedroom visited on the day of the inspection. The proprietor also plans to produce a DVD of the home which could also been shown to prospective residents who are unable to visit, with permission from current residents and their families. Both the manager and her deputy undertake pre-admission assessments. The home does not take emergency admissions. The home has an assessment Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 9 form in place, which meets the required standard. A space should be added for the signature of the assessor. Two pre-admission assessments were reviewed from recent admissions to the home. These were seen to have been completed well and gave detailed and individual information. The home also, where appropriate, uses assessment information from social services to supplement the information they have gained themselves, in order to make an informed decision regarding admission. On the day of admission, a senior member of staff is assigned to admit and help the new residents and their family/representatives. Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. 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. The home has a care planning system in place that is developing well. Resident’s health care needs are met. The medication systems in the home are sound Resident’s privacy and dignity is respected. EVIDENCE: The new owner has introduced a comprehensive new care planning system into the home, which is developing well. A pre printed system has been put into place and then they are individualised where appropriate. Attention needs to be given to this, as whilst some were personalised, information on personal preferences was limited overall. Care plans were seen to be in place for all assessed care needs and daily notes reflected the care provided. Detail on the care, needs to improve on some care plans giving more information for staff, for example, stating what level of assistance is required rather than just saying ‘assist’. Individual care plans are in place for preferences and this gives Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 11 some good information but does not relate to all aspects of care. At the current time life plans are being completed but they are not in place for all residents. The aim of the team is to develop a more person centred approach. Overall the care planning records are good and indicate a proactive and good standard of care. However, staff do need to bring the person into the care plan more. Records show good evidence of 6 monthly care reviews with families and residents. At that time interested parties then sign the care plan and good records show input from all parties. Records show that actual care plans are reviewed regularly and the system in place allows people to see what has changed over a period of time. Overall records show a good level of communication with relatives. Good individual care risk assessments were seen to be in place for residents and these include falls, bathing, hot weather, skin care, etc. Records show that residents see the GP on a regular basis and in a timely manner when required. At the time of the inspection, one resident has a pressure sore, which relates to being unwell and the recent very hot weather. Records show the district nursing team were contacted promptly and an appropriate pressure-relieving mattress is in place. Summer/hot weather care plans were in place for all residents. Weight monitoring is done on a regular basis and records are maintained. Residents weights are also recorded on the care plan review form every month and consideration is given to any weight loss or gain. Medical records show that residents are referred, when appropriate to health care professionals and that hospital appointments are kept. Records show that residents are seeing opticians, chiropodists and the continence advisor. The falls prevention team have also been seeing residents at the home where appropriate. Relative’s spoken to are very happy with home and feel reassured that their relatives are well cared for and that the staff team are genuinely caring of the residents. The medication system was inspected and found to be in very good order. Since taking over the home the manager has ensured that all residents have had a medication review and there is evidence of these along with further reviews. Inspection showed good management of the systems in place including returns. Mar sheets were neat and completed well; they also showed evidence of weekly compliance audits. All medications were checked in well and recorded. They have a two-person administration system whereby one pops the tablet and one administers and there is a signing system so it can be audited. The home needs to give consideration to the legal aspects of this system whereby the person signing the MAR sheet is signing for administering but is not actually carrying out this task. Reference should be made to the Royal Pharmaceutical Societies Guidelines. Staff confirm recent training and the programme shows that further training is planned. Staff spoken to were Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 12 well informed about the residents need for medication and showed a good level of knowledge. Residents spoken to state that staff always treat them with respect and are very good at maintaining and letting them have privacy. Interaction between staff and residents was heard to be caring and respectful. Residents were seen to be very well groomed and wearing personal items. Arran Manor DS0000065865.V309047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Social activities in the home need to develop further. Residents have good contact with family and friends. As far as possible, residents are helped to exercise choice and control over their lives. The food provided is generally good and enjoyed by residents. EVIDENCE: The manager has an activity programme in place and recognises that there is a need to improve, and that this is an ongoing programme. Staff are currently undertaking social care plans and life plans and this will help them identify preferences in relation to activities so they can develop the programme further. At the current time residents spoken to and those who commented are happy with the arrangements but the manager feels that this is an acceptance of what was previously provided and that it could be better and more person centred. The manager is working with the staff to get them to take on this role and training has been provided. Some of the activities provided are baking, Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 14 jewellery making and exercise. One member of staff was seen playing draughts with a resident. Records of activities provided need to improve. Residents spoken to and from satisfaction questionnaires are happy with their daily routine and feel that they have choice within the routines of the home. Upon inspection residents were spending their time in their rooms or in the lounge or conservatory. Rising times were seen to be graduated. Observation showed that staff are very aware of residents routines and choices, as one resident asked for water and the staff member asked whether she would like chilled or warm water today. The home has an open visiting policy and relatives spoken to say that they always felt welcome into the home. The manager reports that lunches, special afternoon teas and small private parties are on offer but it is not clear how people know about these services. Information on local advocacy services are available on notice boards and in the Service Users Guide. Inventories are done on the admission of residents and they are also encouraged to bring personal items for their rooms. Residents spoken to and from records are generally happy with the food offered at the home. Records show that opportunities are given to residents to comment and give suggestions and state preferences. Nutritional records are only recorded if there is an concern regarding the residents intake. Menus were seen to be varied and gave a choice or alternative if required. Records show that residents are having alternatives and different diets. Homemade cakes are often made with the residents. Menus are reviewed regularly and evidence shows that this was done following questionnaire. At the last feedback a side salad has been added to the sandwiches and more fresh fruit is provided. The menus are very resident led. Consideration is being given to suppertime is relation to residents preferences. Afternoon tea and cakes were observed in the dining room with visitors. Residents are encouraged to come to the dining room to promote exercise and social interaction. Residents were obviously enjoying this and the manager reports that this can often turn into a social event. Arran Manor DS0000065865.V309047.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 inspected at least once during a 12 month period. 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 systems in place to help ensure that concerns and complaints will be listened to and acted upon, although the format could be more appropriate to the resident group. The home has systems in place, which help to ensure the protection of vulnerable adults from abuse but training provision needs to be competed for all staff. EVIDENCE: The management team at the home have a proactive approach to complaints or concerns and deal quickly with any raised. Residents and relatives spoken to knew who they would raise any concerns with but records showed that they were not aware of the actual procedure. A complaints procedure is in place. Whilst the content is sound, it was seen to be lengthy and needs to be appropriate to the resident group. This should be reviewed with the resident group in mind. The management team has a logging system in place, but no complaints have been received since new owner/manager has owned the home. Letters of compliment were seen which particularly complimentary of the proprietor/manager, from both previous residents and relatives, one of which described the home as ‘excellent’. Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 16 The home has polices and procedures in place for the protection of vulnerable adults. This included local guidance and information on CRB’s and POVA first checks. Training records show that less than 50 of the staff has up to date training in adult protection. The training programme shows that further training is planned for August 2006. The home needs to ensure that all staff receive this training, including ancillary staff. Arran Manor DS0000065865.V309047.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 at least once during a 12 month period. 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 is well decorated and safe, with the refurbished areas being completed to a very high standard. The home is clean and hygienic. EVIDENCE: A partial tour of the premises was undertaken. The proprietor is carrying out a large refurbishment of the home, which includes all of the bedrooms, some bathrooms and communal areas. The home has two comfortable lounges, a conservatory and dining room. The conservatory has been refurbished to a high standard and is tastefully decorated and accessorized as people would in their own homes. The bedrooms refurbished are very comfortable and again decorated and accessorized to a high standard, which is particularly good for respite residents who do not have to stay in a ‘bare’ room. Whilst pictures and ornaments are in place, residents are free to being in their own items and this was seen around the home. Residents who are in the refurbished rooms were Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 18 very happy with the new facilities. Refurbishment is about to commence on one of the main bathrooms. The home has a pleasant, good-sized garden with patio areas and good access. The proprietor plans to make improvements to the garden in the future, including removing the large shed. Fire safety systems were checked and seen to be in good order. The home has an up to date fire safety risk assessment in place. Security in the home is good. The home does not currently have a maintenance man and this is covered by some-one linked to the home. A more substantive arrangement is planned for the future. It was noted that several light bulbs in the lounge areas had not been replaced, making one lounge slightly dark. There are inherited issues with the hot water/heating system and the proprietor is aware of this and plans to do something about this before the winter. Water temperatures at residents sinks were low – 33oc. On inspection the home was seen to be very clean and no odours were noted. Both residents and relatives were very complimentary regarding the décor and facilities in the home. Residents said that the home was always clean. Arran Manor DS0000065865.V309047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff currently meet the services users needs. Residents are in safe hands with staff at the home and NVQ qualifications are encouraged. The home has sound recruitment policies and procedures. Whilst the home is providing and encouraging staff training, there are still some shortfalls. EVIDENCE: The home has a stable team but is still recruiting to bring the team numbers up and reduce or stop agency use. At the current time, the home uses approximately 4 agency shifts per week. The home supplies 3 care staff in the morning, 3 in the afternoon and 2 at night. The rota shows that at times these numbers are raised depending on resident need. The proprietor and manager also provide an on call rota covering 24hrs. The rota should indicate the designation of the staff (carers/person in charge) and the full names of any staff used including agency. Residents spoken to felt that the staff at the home were available to them and came promptly if they used the call system. Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 20 The proprietor/manager encourages staff to undertake NVQ qualifications. At the current time the home has 42 of its care staff with and NVQ qualification at level two or above. The home has recruitment polices and procedures in place. Staff files were checked at random and found to be in good order with the required documentation and checks in place. Interview records are kept. It is recommended that these be updated to evidence that any gaps in employment have been explored. Checklist systems are in place for both employment and the staff files. The home has a basic induction programme in place and completed records were seen. Staff also sign to say that they have read key policies and procedures and that they have been given copies of the Code of Conduct, Job description etc. The management team are aware of the Skills for Care induction and are giving consideration to implementing this. Training records show that the management provides a good level of training with both statutory and additional training. The home has quite few new staff and is also addressing past shortfalls. Records submitted show that at the current time there are still significant gaps with regard to fire safety and manual handling. The training programme shows that further training is planned in these subjects. Records show that training has been provided in care planning, pressure areas care, catheter care, communication, first aid, dementia awareness and health and safety. Arran Manor DS0000065865.V309047.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is of good character, suitably qualified and fit to run the home. The home has a quality assurance programme in place, which could be developed further. Resident’s financial interests are safeguarded. The home is developing a staff supervision system. The health and safety of residents and staff is promoted. EVIDENCE: The proprietor at the home is also the registered manager. The deputy manager has been in post some while and is currently applying for registration Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 22 as the new manager of the home allowing the proprietor to step down. Residents and relatives speak highly of the manager, saying that she is approachable and available to speak to should the need arise. Staff spoken to say that the management of the home is very good and that they feel supported in their roles. The management team have a wide range of satisfaction questionnaires in place, which they have just started using. They felt that they could not use them straight away until people had got use to the new ownership/people at the home and experienced the services offered. Results of those completed so far were available for inspection and the manager plans to publish the results once they are all returned. From the records, (over 50 return so far), residents are happy living at the home and relatives who helped completed the survey are also positive. The questionnaire covers a wide range of subjects and is very care and choice orientated. Where concerns or queries are raised the team must ensure that they evidence that these have been addressed as far as possible. The manager has also carried out 6 monthly care/placement reviews and records of these show that relatives are also very happy with the care and services provided at the home. Gp’s are happy visiting the home and have said ‘carry on the good work’. Staff are very positive about working at the home with regard to the care they are able to give to residents and the training provided. Minutes of meetings also show that the manager holds meetings for residents and groups of staff where a wide range of subjects are covered and people are asked for their views. The home also audits some of its internal systems such as medication, which is good practice and this could be developed to encompass other areas. The home does handle monies on behalf or residents. This is managed through an account at the home with families giving the home cheques and the home paying chiropodists, hairdressers as necessary. A petty cash float is held should any residents want access to cash amounts. Records are held and these should evidence of transactions and running balance and receipts are available. The manager has started staff supervision in July and has given staff appraisals forms to fill in and return. From discussion and records, there has been a lot of ongoing, hands on, practical supervision and training put in over last few months and the team are now moving forward with formal supervision. The manager has taken a good considered approach and the CSCI look forward to this developing further. The home has a health and safety policy in place. Accident records were inspected and seen to be in good order with the manager undertaking a review of accidents on a monthly basis looking for trends etc. that could be addressed. Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 23 Comprehensive environmental risk assessments are in place and were completed in April 06. These were very good and could be developed further to encompass safe working practice risk assessments. This was discussed with the manager. Random sampling of safety and maintenance certificates for fixtures and equipment in the home, show that these were up to date and in order. Low surface temperature radiators are in place and water temperatures are monitored and recorded. Window restrictors are in place. Arran Manor DS0000065865.V309047.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 3 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 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/a 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 15 Requirement The registered person must continue to develop the care plans in relation to social care, personal preferences and sufficient detail in the care to be provided. The registered person must continue to develop the activities programme in the home based upon residents’ preferences and needs. The registered person must ensure that the complaints procedure is appropriate to the needs of the residents. The registered person must make arrangements by training or other measures to ensure that residents are protected from abuse. The registered person must ensure that there is an adequate ongoing maintenance support at the home and that the hot water system is attended to. The registered person must ensure that staff are trained in relation to statutory requirements. DS0000065865.V309047.R01.S.doc Timescale for action 14/11/06 2 OP12 16 30/11/06 3 OP16 22 30/10/06 4 OP18 13 (6) 30/10/06 5 OP19 23 30/11/06 6 OP30 18 30/11/06 Arran Manor 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 2 3 4 5 Refer to Standard OP1 OP3 OP9 OP28 OP33 Good Practice Recommendations The registered person should give consideration to the format of the written Service Users Guide. The registered person should ensure that the person carrying out the pre admission assessment, signs the assessment form. The registered person should ensure the legal aspects of the current medication system they are using. The registered person should continue with the NVQ training programme at the home. The registered person should give consideration to extending the internal audit system in the home and recording what action has been taken to any concerns raised during feedback questionnaires. The registered person should develop safe working practice risk assessments. 6 OP38 Arran Manor DS0000065865.V309047.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 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 Arran Manor DS0000065865.V309047.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!