Inspection on 09/05/06 for Barnfield Manor Care Home

This inspection was carried out on 9th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Barnfield Manor Care Home 28/07/09

Barnfield Manor Care Home 07/05/09

Barnfield Manor Care Home 03/06/08

Barnfield Manor Care Home 14/11/07

Barnfield Manor Care Home 09/01/07

Barnfield Manor Care Home 06/09/06

Barnfield Manor Care Home 22/02/06

Barnfield Manor Care Home 05/10/05

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

CARE HOMES FOR OLDER PEOPLE Manor (DE), The Barnfield Close / Off Heath Road Holmewood Chesterfield Derbyshire S42 5RH Lead Inspector Susan Richards Unannounced Inspection 9th May 2006 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 Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 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. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Manor (DE), The Address Barnfield Close / Off Heath Road Holmewood Chesterfield Derbyshire S42 5RH 01246 855899 01246 852953 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) Hallmark Healthcare (Holmewood) Ltd Mrs Anne Marie Gaunt Care Home 39 Category(ies) of Dementia (39) registration, with number of places Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration is to be phased – Units 1 and 2 (up to 26 service users) is currently agreed. Accommodation of service users in Unit 3 (14 service users) must be formerly agreed by the Commission prior to use subject to achievement of identified works/upgrading to that area of the building. Achievement of an identified and agreed schedule of upgrading, repair and renewal to the building, including the fire officer’s requirements within agreed timescale. Care staff must undertake recognized dementia care training within agreed timescale. 22nd February 2006 2. 3. Date of last inspection Brief Description of the Service: Barnfield Manor Care Home (formerly The manor DE) provides personal care and support for up to 40 older persons with dementia. Hallmark Healthcare Limited (Holmewood), the registered provider were granted registration approval in May 2005. Since registration there has also been a further change by way of the responsible individual. The home comprises three separate areas of accommodation for service users, each having its own dedicated facilities, including lounge/dining rooms, bathrooms and toilets. Adequate car parking is provided, together with accessible and secure dedicated garden areas. There is a separate single storey building located within the grounds, which provides a central laundry and staff facilities. The home is located in the village of Holmewood, close to shops, a post office and local amenities. It is on a direct bus route to Chesterfield and within a short distance of Junction 29 of the M1 motorway. The premises are currently subject to a programme of repair and total renewal and redecoration, completion of which is a condition of the home’s registration. There is a passenger lift and emergency call system provided, together with handrails to corridors and grab rails to toilets. Bedrooms provide a majority of single room accommodation, many having en suite facility. Hallmark have appointed a new manager for the home - within the last 2 weeks prior to the inspection and residents receive care and support from a team of care and hotel services staff. The range of fees charged by the home, are detailed within the home’s service user guide/statement of purpose. For residents who receive assistance with funding via Derbyshire County Council Social Services Department, fees are in accordance individual purchasing contracts between Social Services and the home and are detailed within the written terms and conditions provided by the Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 5 home to the resident. For residents who are privately funded details of fees are set out within individually written contracts between the home and resident. The range of fees charged as at 09 May 2006 are as follows: Standard fees charged are £286.80 - £316.80 per week. Private fee charged are £315.00 - £340.00 per week. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and there were 18 residents accommodated. During this inspection the majority of the Department of Health’s key National Minimum Standards for older persons were assessed. The focus of the inspection was on outcomes for residents accommodated and case tracking was used as part of the methodology. The Inspector was unable to hold in depth, meaningful discussions with residents due to individual’s given mental capacities. However, their care and associated records were inspected and the organisation and delivery of individual care and service provision observed and discussed with staff in the home and a small number of relatives. A full tour of the premises was also undertaken and maintenance records were examined. Discussions were also held with acting management about the management arrangements in the home. What the service does well: What has improved since the last inspection? An identified programme for the repair, upgrading and total renewal and redecoration of the home has commenced with a timescale for completion identified. At the previous inspection for this service a new format for the recording of residents needs assessment and care-planning information had been introduced for many residents. The transfer of information onto the revised format had been fully completed at this inspection, with significant improvement in the standard of information recorded. A review of menus and food provided for residents was well underway offering improved quality and choice. The temporary management support engaged whilst recruitment of a manager for the home took place had promoted a degree of stability for the home, and Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 7 staff morale was slightly improved given the very recent recruitment of the new manager for the home 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. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 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 Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Service users needs were reasonably well recorded, although the lack of information detailing their social, hobbies and religious needs together with that relating to their known lifestyle preferences, individual wishes and likes and dislikes in respect of their daily routines compromised the delivery of a person centred approach to individual care. The quality outcome in this area is adequate. This judgement has been made using available evidence, including a site visit to the home. EVIDENCE: Of the 18 residents accommodated (including 3 admitted for the purposes of respite care) case tracking was undertaken for 3 residents (including one admitted for the purposes of respite care). Residents’ recorded needs assessment information was examined and discussions were held with staff about the assessment of residents needs, together with a small number of relatives present. The Inspector also observed aspects of the organisation and delivery of care and support to residents. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 10 Individual’s care needs assessments were reasonably well recorded and regularly reviewed, although detailed little information in respect of individual’s past social history, and preferred lifestyle preferences, wishes and likes and dislikes. There were no residents accommodated with differing or special cultural needs. See also Staffing section of this report regarding staff numbers and training in respect of meeting residents’ needs. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 For the most part residents’ health care needs were being met, although insufficient staffing levels, together with a lack of information regarding individuals known lifestyle preferences, wishes, likes and dislikes in respect of their daily living routines resulted in a task-orientated approach to care rather than a person centred one and staff were not always following the proper procedures in respect of medicines storage, recording and administration. Quality outcome in this area is adequate. This judgement has been made using available evidence including a site visit to the home. EVIDENCE: Case tracking was undertaken in respect of three residents and discussions were held with the acting manager, staff and relatives about the care and services provided to residents and their care plans. The Inspector also observed aspects of the organisation and delivery of care and support to residents, including the serving and assistance with lunch. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 12 There were written care plans for each of the residents case tracked, formulated in accordance with their needs assessment information within a comprehensive framework of risk assessment. Care plans were reflective of recognised clinical guidance concerned with the health care of older persons and had regularly recorded reviews. However, for one resident who had a high risk scoring in terms of their nutritional status recorded, there was no written care plan in place detailing required care interventions in respect of their nutritional requirements. Although there was a standardised format for the recording of any consultation regarding residents care plans with the representative acting on their behalf, these were not completed. The arrangements for the management and administration of medicines were also examined. A number of deficits in practise were identified here in relation to the storage, recording and administration of medicines. At the previous inspection for this service in February 2006 deficits were identified in relation to poor practises in the recording of residents medicines administration record (MAR) sheets, which were still evident at this inspection. Serious concerns have been raised separately in writing with the registered provider in respect of this and all deficits were fully discussed with the manager during the inspection. Medicines training had been organised with dates set for staff responsible for medicines to attend Laundry arrangements were discussed in respect of personal clothing. Residents clothing was labelled and they were suitably dressed. Positive feedback was received from one relative regarding the care taken by staff with residents clothing. Staff was observed to be respectful in their approaches to residents. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 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 & 15 The quality and choice of food offered had significantly improved since the previous inspection for this service, although insufficient staffing levels impacted on the assistance provided to residents at mealtimes and the social, religious and recreational interests of residents were not effectively promoted or met. The quality outcome in this area is poor. This judgement has been made using available evidence, including a visit to the home. EVIDENCE: The provision of social care and activities was examined via the case tracking process and including observations and discussions with staff and relatives. Staff was observed to work hard to meet the personal, health and hygiene and safety needs of residents. With the exception of music playing continuously, there were no activities observed to take place, either group or individual during the course of the inspection. Staff advised that an outside group provide an exercise session for residents on a monthly basis and that singing entertainers visit the home periodically. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 14 Due to the given mental capacities of residents, their individual ability to make informed choices was variable and extremely limited. Information was not recorded for any resident case tracked in respect of their social history or known daily living routines and preferred lifestyles. The home’s service user guide clearly sets out the intended provision activities for residents, both within and outside the home, which is comprehensive in its written detail, but in fact is not delivered. One the day of the inspection, it was a sunny and pleasant day. Staff was not able to take any residents out into the village or local community as there were insufficient staffing levels. One staff member advised of the plan to recruit an activities co-ordinator for the home. A number of relatives visited the home at various times throughout the day and said that they visited regularly and that there were no restrictions on visiting. Discussions were also held the cook and staff about meal provision for residents. Menus were also examined and the inspector observed the organisation and serving of lunch and drinks to residents, together with the assistance and support provided for them. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 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 & 18 There were suitable systems and information in place to enable complaints about the service to be made and concerns raised, although a complaint made six months ago had not been effectively dealt with or responded to. There were suitable systems in place to promote the safeguarding of residents from abuse. The quality outcome in this area is adequate. This judgement has been made using available evidence, including a site visit to the home. EVIDENCE: A written complaints procedure was displayed and information regarding how to complain was provided within the service user guide. Relatives spoken with knew how to complain and/or raise concerns. The complaints record was examined and discussed with the manager and the home’s procedures relating to safeguarding adults also discussed. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 16 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, 20, 21, 22, 23, 24, 25 & 26 The programme for the total upgrading and renewal of the fabric and some equipment in the home in accordance with identified conditions of registration has not yet been completed and some aspects of infection control practises in the home were not in accordance with recognised procedures. The quality outcome in this area is poor. This judgement has been made using available evidence, including a visit to the home. EVIDENCE: A full tour of the building was undertaken in order to assess progress with the agreed programme of repair, upgrading and renewal, which was within the extended timescales agreed, but with substantial work to be undertaken. Provision of moving and handling equipment was inspected and discussions were held with staff about the moving and handling needs of residents, and their a number of residents recorded care needs assessment and care planning information examined in respect of those needs. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 17 Staff practises were observed in relation to the handling and storage of clean linen and the availability of information for staff in respect of the use of cleaning materials and dealing with spillages in the home was discussed with staff. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 18 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 & 30 Care staffing levels in the home are insufficient. Not all aspects of recognised recruitment procedures were properly applied and there were deficits in the induction and training arrangements for staff, some of which had been identified by the new manager. Quality outcome in this area is poor. This judgement has been made using evidence available, including a site visit to the home. EVIDENCE: The arrangements for staffing provision in the home were discussed with the manager, staff and relatives/resident representatives, and the arrangements for staff recruitment, and their induction and training were also discussed with the manager and staff. Records were also examined in respect of these, including staff duty rotas and practises were observed during the inspection. At the previous inspection for this service serious concerns were raised separately in writing regarding the insufficient care and hotel services staffing levels provided. A written response was received from the registered provider. The Inspector assessed compliance at this inspection in respect of staffing level provision. There were improvements the arrangements for kitchen staff hours, which were satisfactory. There were no improvements in the provision of care staff. Areas where this has impacted in terms of care and service provision are detailed under the relevant sections of this report. Failure to comply is raised Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 19 with the registered provider, separately and in writing and may result in enforcement action being taken. Also at the previous inspection for this service, deficits in recruitment practises were identified in respect of records kept regarding staff employed in the home. The personal records of four staff were examined on this occasion. These contained details in respect of their recruitment, although each had only one written reference provided. Information regarding induction and training undertaken by them was variable. Serious concerns have been raised separately in writing with the registered provider in respect of recruitment procedures operated by the home - the lack of two written references being provided for each staff member employed The acting manager had only been in post for approximately 2 weeks. She had begun to undertake training needs analysis in relation to staff employed, and provided information recorded by her so far, with a view to developing a training plan. It is a condition of the home’s registration that all care staff is provided with suitable dementia care training. A rolling programme had commenced in respect of this, with dates for completion. The personal records of four staff were examined. These contained details in respect of their recruitment, with each having only one written reference and also their training, which was variable in their content. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 20 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): 33, 36, 37 & 38 Management systems in the home, including that relating to communication, consultation and supervision have been neglected for a substantial period of time, although strategies identified by the new manager, if effectively implemented will have a positive impact on these. The quality outcome in this area is adequate. This judgement has been made using the evidence available, including a site visit to the home. EVIDENCE: There has been no registered manager for the home since January 2006. The registered provider had recently forwarded written notification to the Commission advising of the appointment of a manager, who had been in post approximately 2 weeks by the time of the site visit to the home. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 21 Discussions were held with the new manager and management support staff regarding strategies for the assessment and monitoring of the quality of services provided to residents in the home. With the exception of the monthly visits on behalf of the registered provider and reports of those visits, there are no formal mechanisms employed for in respect of quality assurance and monitoring or seeking the views of residents and their families/representatives about service provided. Discussions were also held with them and staff about the arrangements for staff supervision. A number of records, which are required to be kept in the home, were examined during the site visit/inspection process. These are referred to under the relevant section of this report and also included maintenance records and records of accidents and incidents. Discussions were also held with the newly appointed maintenance person for the home. Certificates of maintenance were in place, although there was no record in respect of electrical hardwiring testing and maintenance and the certificate relating to the hot and cold water system maintenance was awaited – the administrator advised that this had recently been undertaken. See also comments under staffing section re staff training, which includes core health and safety training for staff. During the tour of the building two first aid boxes were examined. These were not properly stocked. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 22 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 3 2 3 2 3 2 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X 1 2 2 Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14 Requirement It must be ensured that there is a recorded needs assessment in place for each resident, which contains all information in accordance with NMS 3 for Older Persons and which relates to their known lifestyle preferences, individual wishes and likes and dislikes in respect of their daily living routines. Timescale for action 31/07/06 2. OP7 12, 13 & 15 3. OP9 13(2)& 17(1(a Sch3 Residents written care plans 31/07/06 must be formulated in accordance with their individually risk assessed needs and be reflective of their known lifestyle preferences, individual wishes and likes and dislikes in respect of their daily living routines. 09/06/06 Gaps must not be left in medicines administration record (MAR) sheets. When a medication is not administered as prescribed to any service user, the coded reason for its non-administration must be recorded on the MAR sheet and the reason clearly recorded in the service users daily evaluation DS0000064197.V289858.R01.S.doc Version 5.1 Page 24 Manor (DE), The record sheet. NB Previous timescale 30/11/05 – raised as serious concern during this inspection. 4. OP8 23 (OP 22 also applies here). It 31/07/06 must be ensured that suitable moving and handling equipment is provided in accordance with residents assessed needs. (From report of 06/02/06 by 30/04/06). There must be a safe system for 09/05/06 the administration and recording of medicines. Staff must record medicines administration (gaps must not be left blank) or when a medication is not administered to any resident, the coded reason for this must be recorded on the MAR sheet and the reason clearly recorded in the residents daily evaluation record sheet. (From inspection report 05/10/05 by 30/11/05. Raised in writing as serious concern during this inspection). Suitable arrangements must be made for the safekeeping and storage of medicines. Arrangements must be made to enable residents to engage in local, social and community activities. (From inspection 05/10/05 by 31/01/06). It must be ensured that any complaint made under the complaints procedure is fully investigated and responded to. In this instance the complaint made to the provider in December 2005. (From the inspection report of 06/02/06 by 31/04/06). Compliance must be achieved DS0000064197.V289858.R01.S.doc 5. OP9 13 & 17 6. 7. OP9 OP12 13 16 09/06/06 31/08/06 8. OP16 22 30/06/06 9. OP19 23(1)& 31/07/06 Page 25 Manor (DE), The Version 5.1 (2) 10. OP26 13 11. OP27 18 12. OP30 13 & 18 13. OP37 17 & 19 14. OP31 Sec 11 CSA 2000 with the programme of upgrading, repair and renewal of the building in accordance with that stated conditions of the home’s registration & extended timescale agreed with provider). There must be suitable systems and arrangements in place to promote good infection control and to prevent infection. In this instance, staff practises concerned the handling of linen. With regard to the size of the home, the statement of purpose and number and needs of residents, there must be at all times suitably qualified, competent and experienced staff working at the home in such numbers as are appropriate for the health and welfare of residents. (Raised as a serious concern in writing - From the inspection report of 06/02/06 by 03/03/06). (OP 38 also applies here). The training plan for staff must be fully completed – staff must receive training appropriate to the work they are to perform by way of an identified programme, (including induction) with key priority to core training. NB Previous timescale 31/03/06 Records must be kept in respect of each staff member employed in accordance with items detailed under Schedule 4 of the Care Homes Regulations 2001 – including two written references. (From inspection of 05/05/05 by 31/12/05 – raised separately in writing as a serious concern during this inspection). The manager of the home must apply to the Commission for registration under the Care Standards Act 2000 and in DS0000064197.V289858.R01.S.doc 30/06/06 09/06/06 30/06/06 30/06/06 31/07/06 Manor (DE), The Version 5.1 Page 26 15. OP33 24 16. OP36 18 17. OP38 13 18. OP38 13 accordance with revised application process). A system must be established for the continuous review and improvement of the quality of care provided at the home, and must provide for consultation with residents and their representatives. A formal system of individual staff supervision must be operated in the home in accordance with this standard. There must be suitably systems to prevent the spread of toxic conditions in the home – in this instance written hazard analysis information for staff in respect of cleaning materials/products used. There must be suitable arrangements in place to ensure that first aid equipment/boxes are properly stocked. 31/08/06 31/07/06 30/06/06 30/06/06 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. Refer to Standard OP7 OP7 Good Practice Recommendations There should be evidence that service users, or where appropriate, their representatives are consulted about their care plans, including any revisions to them. The registered persons should consider staff training in relation to recognised practices for sensory care associated with dementia, such as sneozelen. Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Manor (DE), The DS0000064197.V289858.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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