Inspection on 28/11/07 for Dryclough Manor

This inspection was carried out on 28th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Dryclough Manor 16/01/07

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Dryclough Manor 20 Shaw Road Royton Oldham Lancashire OL2 6DA Lead Inspector Mrs Fiona Bryan Unannounced Inspection 28th November 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Dryclough Manor DS0000067060.V354612.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. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dryclough Manor Address 20 Shaw Road Royton Oldham Lancashire OL2 6DA 0161 626 7454 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) drycloughmanor@yahoo.com Dryclough Manor Ltd Miss Jacqueline Byrne Care Home 42 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (42), of places Physical disability over 65 years of age (6), Sensory Impairment over 65 years of age (4) Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and competent manager who is registered with the Commission for Social care Inspection. The home is registered for a maximum of 42 service users to include: *up to 42 service users in the category of OP (old age not falling within any other category); *up to 22 service users in the category of DE(E) (dementia over 65 years of age); *up to 6 service users in the category of PD(E) (physical disability over 65 years of age); *up to 4 service users in the category of SI(E) (sensory impairment over 65 years of age) 16th January 2007 Date of last inspection Brief Description of the Service: Dryclough Manor is a privately owned care home, registered to accommodate 42 people. The home is situated a short distance from the centre of Royton, near to a junction of two main roads, and is within easy reach of shops and public transport services. The building is a detached property with pleasant gardens, a patio area and car parking space to the front. Accommodation for residents is provided on the ground and first floors, with two passenger lifts in operation. The home has 38 single bedrooms and two double bedrooms; 36 of the rooms have en-suite facilities, with two of these being shared. There is ramped access to the front entrance. The weekly fee is £333 – 378.50, which does not include the following: hairdressing; toiletries; chiropody. A copy of the commission’s most recent inspection report is displayed in the reception area. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place over two days on Wednesday 28th and Thursday 29th November 2007. The manager was not told beforehand of the inspection visit. All key inspection standards were assessed at the site visit and information was taken from various sources, which included observing care practices and talking with people who live at the home, the manager and other members of the staff team. Three people were looked at in detail, looking at their experience of the home from their admission to the present day. Since the last key inspection, a pharmacist inspector carried out a random inspection on 17th September 2007. This was in response to concerns raised by the PCT about how staff at the home were managing medicines. The inspection in September found that practices were poor and five requirements were made to ensure that improvements were made. A short report is available on request about the inspection. At this inspection the pharmacist inspector assessed how the home had addressed the requirements made. A partial tour of the building was conducted and a selection of staff and care records was examined, including care plans, employment records and staff duty rotas. Before the inspection, comment cards were sent out to residents and relatives asking what they thought about the care at the home. Two people responded. We also sent the manager a form (AQAA) before the inspection for her to complete and tell us what she thought they did well and what they need to improve on. Information from both of these sources has been used in the report. What the service does well: The home provided a pleasant, comfortable environment for residents to live in. Residents liked their rooms and said that they were helped to keep them clean, tidy and free from smells. The home had a lively atmosphere; staff were seen chatting with residents and residents were seen moving around the home as they wished. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 6 Residents said they had been given useful information about the home before they decided to live there and had found the information gave an accurate reflection of life at the home. Residents are assessed before they come into the home so the manager can make sure their needs can be met. Residents said staff were prompt in calling their doctor if they were unwell and felt they were looked after very well. Comments included “staff are very good” and “staff are very, very good – they understand what help I need”. Residents were very complimentary about the food provided at the home. On the day of the site visit mealtimes were observed to be very sociable, food portions were good and there was very little waste as all the residents said their meals were “delicious” and the majority ate extremely well. Residents and staff had confidence in the manager and said she was approachable and would listen and act on their concerns. Staffing levels were sufficient to meet residents’ needs and the procedures in place for recruiting new staff ensured that proper checks were made to confirm their suitability. What has improved since the last inspection? What they could do better: Care plans and had been written and risk assessments undertaken, which, in the main, addressed residents’ needs, but staff need to work on making sure that they are updated as soon as there are changes to a resident’s condition. As stated previously, the manager had addressed some issues that were raised at the random inspection about the management of medicines but other matters were identified at this inspection that need addressing. Activities and opportunities for social interaction are provided by the home but could be expanded on; further consultation with residents about their preferences and development of the key worker system may help to identify ways in which this area could be enhanced. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 7 Staff need further training in safeguarding adults, moving and handling and fire safety. Formal supervision sessions should be held with staff to further identify their training needs. The manager needs to review staff practices in respect of moving residents as some unsafe practice was observed. 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. Dryclough Manor DS0000067060.V354612.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 Dryclough Manor DS0000067060.V354612.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Assessments are undertaken and information is provided to prospective residents so they can choose a home that will meet their needs. EVIDENCE: A service user guide was displayed in the reception area of the home, which contained all the necessary information to inform prospective residents about the services the home could offer. The print in the guide was quite small and a discussion was held with the manager about reviewing the format to make it easier for people to read. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 10 One resident said she had visited four homes, including Dryclough Manor, and had been able to choose the home that she felt would most meet her needs. She had been given a “brochure” with information about the home and had found that life at the home was as described in the guide. Three residents were case tracked. Assessments had been undertaken for all three people before they came into the home. One carer said that either the manager or the assistant manager went to assess prospective new residents and told the rest of the staff team about their care needs before they were admitted. Dryclough Manor DS0000067060.V354612.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. This judgement has been made using available evidence, including a visit to this service. The health and personal care residents receive is generally based on their individual needs; the procedures for managing medicines, although better, continue to need further improvement. EVIDENCE: Three residents were case tracked. Care plans had been developed for all the residents, which were fairly person-centred and which were reviewed monthly. Care plans had not been written to address all the care needs of some residents, for example, one resident had recently been in hospital and their care needs had increased but no care plans had been written regarding their pressure area care or nutritional needs. Another resident was diabetic and was being monitored by the district nurses; their care plan however should still have provided information to the carers about the signs to be aware of and the action to take if the resident had low or high blood sugar levels. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 12 Risk assessments had been carried out for moving and handling, nutrition, pressure care and risk of falls and these had been reviewed monthly. On occasion, risk assessments should have been reviewed earlier as there had been changes to the resident, for example, one resident had fallen but their risk assessment had not been further reviewed to consider if any other interventions were needed to reduce the risk of more falls. Records showed that residents had seen GP’s, dentists and opticians. One resident said staff were prompt in getting their GP to visit if they were unwell. Staff were knowledgeable about each resident’s care needs and preferences regarding daily routines, and were able to describe individuals’ likes and dislikes. Since the last key inspection the CSCI has received information from Oldham PCT that there were concerns about how medicines within the home were being managed. As a result of this information, a pharmacist inspector carried out a random inspection on 17th September 2007. Procedures in respect of the management of medicines were, at that time, found to be poor and five requirements were made to improve practices. A short report about this inspection is available on request. The pharmacist inspector returned to the home at this inspection to assess compliance with the requirements made. The manager had worked very hard to improve the way medication was handled and recorded. The manager has checked, audited, the handling of medication regularly. These audits highlighted errors, which were made, and staff were told about them to help them improve their practices around medication handling and recording. The staff have also been on a medicationtraining course. However, despite these facts staff were still making errors of recording and administration, which may put residents’ health at risk. The policies have been updated and, in general, gave the staff dear guidance on safe medication handling. The policies also gave clear guidance on the safe handling of homely remedies, on how to support people who were looking after their own medicines and on the safe handling of medicines when residents were away from the home. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 13 The manager showed she had a good understanding of how to keep clear records and how to maintain accurate records. There were some examples of really good record keeping, one record showed exactly why a resident had not taken their medicine as the doctor prescribed. Other examples of good recording keeping included records which showed exactly when medication is changed by the doctor and when courses of medicines, such as antibiotics, are complete. The records of medicines received or carried over from the previous month were generally clear and accurate, however some medication could not be tracked because the records of receipt and administration were inaccurate, so it was not always possible to tell if medication had been administered properly. The medication records for eight residents were looked at in detail alongside the medication held in the home for each of these residents and serious concerns were found in each set of records. One resident could not be given one of his tablets for three days because they had been sent back to the pharmacy by mistake. There were a number of ‘gaps’ on the administration record chart, where staff had not signed if they had given medicines to the residents. Some residents’ charts had not been signed for two days but the medication had been administered. Other residents’ medication had not been accurately recorded when it arrived in the home so the records could not show it had been given properly. One resident’s eyesight was at potential risk from harm because staff were administering eye drops which might have been out of date because the date of opening had not been recorded but the drops had been dispensed in August. A further serious concern was that the manager was removing medicines from its original packaging and placing it in other containers because she didn’t always trust the staff to manage medication properly. This practice is known as secondary dispensing and is a high-risk practice, which must not continue. The manager assured us that the practice would stop at once. At the last inspection it was a concern that people who looked after their own medicines had not been assessed to see if they could manage their medicines safely. These residents had still not been assessed. It is vital in order to safeguard residents’ health that these assessments are made. The records for one lady who looks after her own medicines showed that she had possibly ‘run out’ of her medication, however this lady showed us that she had plenty of medicines, in fact she complained that she had so much medication that she had ‘nowhere to keep her jumpers’. It is of further concern that staff do not keep a record of medication held by residents, to ensure they have an adequate supply. It is of further concern that this lady did not have a suitable place in which to store her medicines safely. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 14 The procedures satisfactory. for storing and recording controlled medicines were Residents looked relaxed, comfortable and well cared for on the two days of the site visit. Residents said staff were very kind and treated them with respect. One resident said, “Staff are very, very good – they do understand. Jackie (the manager) watches over them”. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The day-to-day routine of the home, including mealtimes, was relaxed and informal and met service users’ needs. EVIDENCE: Residents are able to make choices and decisions for themselves. They said they were able to get up and go to bed when they wished and spend time in their own rooms or join other residents in the lounges. Routines seemed flexible, for example, one resident was observed eating a late lunch, which had been saved for her as she had been visiting the hairdresser at lunchtime. Information about advocacy services was displayed on a notice board and residents said they were encouraged and assisted to maintain family contacts and their visitors were made welcome. Some residents went out of the home regularly with friends and family and two members of staff were observed coming to take one of the residents for lunch at a local pub, which they were doing in their own time. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 16 An activities organiser is employed at the home for three days per week and a programme of activities was displayed on the notice board in the lounge. The activities organiser kept a record of all the events that had taken place and who had participated. Activities included bingo, arts and crafts, dominoes, gardening and sing alongs. One resident said that a minister from the local church visited on the first Thursday of every month to offer communion for those who wished. Care files did not contain a lot of information for some residents about how they liked to spend their time and the range of activities that was offered was not extensive. The manager acknowledged that this was an area that could be further developed, particularly for those residents that do not want to join in with group activities. A key worker system is in operation at the home, although staff described this as being mainly a practical role, for example, helping residents to keep their wardrobes and rooms tidy. Further expansion of the key worker role could help to identify individual social needs and ways in which they could be met. Examination of the menus showed that a nutritious and varied diet was provided by the home. Residents had a choice of cereals, porridge, grapefruit and toast for breakfast and a cooked breakfast was offered on Sundays. Typical food for the main meal of the day included roast dinners, cheese and onion pie, cottage pie, casseroles, plaice and lamb chops. Lighter teas included food such as cauliflower cheese, smoked haddock, poached egg on toast, fish fingers, jacket potatoes, soup, sandwiches and salads. The menu for the day was displayed on a white board in the dining room. Residents said there was not normally a choice of main meal but if they wanted an alternative they could ask and they would be offered another option. Lunch on the second day of the site visit was beef casserole and mashed potato or rice, and dessert was rice pudding. Although the menu only stated that beef was on offer, some residents were given steamed cod and parsley sauce, mashed potatoes and peas. Both the beef and the cod looked and smelled appetising and residents said the food was delicious. Meal portions were good and it was observed that there was very little waste, as most of the residents ate all their meal. We tried a sample of the beef casserole and it was very flavoursome. Residents said there was normally a choice of three or four things for tea. On the second day of the site visit tea was hot dogs, pork luncheon meat sandwiches, turkey and stuffing sandwiches, tongue sandwiches, or ham salad and dessert was vanilla sponge and custard, melon or yoghurts. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 17 Residents’ comments about the food included “Breakfast is good, there is a choice of all the things I like – orange and grapefruit juice. On Sundays there is a cooked breakfast”, “Very nice food”, “the food is very good” and “the food is wonderful. Staff come round with cups of tea – it’s tea all day up here”. One resident did say that they thought tea was served too early, although they went on to say that supper was served at about 7pm which was usually teacakes or similar and that they liked to have a cup of horlicks at about 9pm. The manager said that tea could be saved until later for any resident who wasn’t ready to eat it at the normal time. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents felt confident that their complaints would be taken seriously but all staff need to attend safeguarding adults training to ensure they are fully aware of the procedures to follow. EVIDENCE: The home’s complaint procedure is provided in the service user guide, which is displayed in the reception area. Residents said that if they had any concerns they would complain to the manager and they were confident she would listen to them and sort any problems out. A record of complaints was kept. This showed that one complaint had been made and detailed how it had been investigated and resolved. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 19 Since the last inspection two incidents have occurred at the home that have been investigated under safeguarding adults’ procedures. One of the incidents has been investigated and the findings were that the home had acted appropriately. A final meeting to confirm the outcome in the second case is to be held. The manager had kept records of both incidents and the actions she had taken, which showed that she had taken appropriate steps to protect the residents, although she had not notified the CSCI until the investigations by the safeguarding officers from Oldham Social Services had been completed. This was discussed with the manager, as she should have alerted the CSCI as soon as it was apparent that incidents had taken place that had adversely affected any residents. Staff said that they had undertaken training in recognising signs of abuse and protecting residents. This training had been in the form of watching a DVD and answering questions to test their understanding. One member of staff was aware of the procedure to follow but another member of staff was less sure. Arrangements should be made to ensure that all staff attend the Alerter training provided by Oldham Social Services so they are aware of the Local Authority procedures. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home was well maintained and provided comfortable living accommodation for residents. EVIDENCE: A partial tour of the home was conducted. The home was clean, tidy and welcoming. Several lounges gave residents a choice as to where to spend their time and there was a lively atmosphere with visitors coming and going and staff interacting well with residents. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 21 One lounge was quieter, with about seven residents sitting, mostly dozing. The room was warm and cosy with flowers and pictures, and bay windows making it bright and airy. Another smaller area provided a bookcase filled with books, a public payphone and an armchair for residents wishing to make phone calls in private or sit and read quietly. A larger lounge and two dining areas, which were all open plan offered other options for residents to spend time and some residents sat in the reception hall outside the manager’s office, watching people coming and going and passing the time of day. The maintenance person was in the process of decorating the dining areas and the manager said new carpets had been ordered for them. On the first floor a sitting area on the landing provided a piano, computer and settees, etc., and residents sat here whilst they waited to visit the hairdresser who had a small salon along the hallway. Residents said they were happy with the cleaning and laundry services provided at the home. There was no staff call lead in one resident’s room, although her care plan said that she was at risk of falling and stated that the call lead should be within easy reach. The manager said she would ensure a lead was provided. The manager had prepared a programme of redecoration for the home, prioritising which rooms needed refurbishment and was ensuring this work was carried out. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 22 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 good. This judgement has been made using available evidence, including a visit to this service. The home was sufficiently staffed and recruitment procedures ensured that service users were protected. EVIDENCE: At the time of the site visit 40 people were in residence at the home. Six carers were on duty in the morning and afternoon and five carers were on duty between 5pm and 10pm with four carers on duty overnight. The manager was supernumerary to these numbers. Examination of the staff duty rota confirmed that these staffing levels were the norm. Residents and staff said they felt there were usually enough staff to meet the needs of the people living at the home. The manager reported in the AQAA that 43 of care staff have successfully completed NVQ training and a further 12 staff are undertaking the training at the present time, which will mean that when they have completed their training, 75 of staff will have this qualification. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 23 The personnel files for three staff members were examined. All contained evidence that the all the necessary checks had been made before they started work at the home. We spoke to one staff member who was quite new to the home, who confirmed she had been asked to supply two references and had applied for and obtained a CRB before starting work. An employee induction form was included in one new staff member’s file. The staff member had only commenced work at the home on 26th November 2007 and their induction record had been signed to say that training had been given on 27th November 2007. However, the quality of the training was in doubt as it appeared from the record that training had been given in too many topics for them to have been covered in any depth, i.e., according to the record, training had been completed in moving and handling, use of lifting equipment, the key worker system, abuse, confidentiality, death and dying, bathing, recording of care, food hygiene and others. Following discussion with the manager, it was apparent that the induction training does not, at the present time, meet Skills for Care specifications and the manager needs to review the present induction arrangements. Training records showed that a number of staff had undertaken refresher training in the management of medicines and some staff had received training in dementia care. Staff said they were due to have moving and handling and fire safety updates. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 24 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. This judgement has been made using available evidence, including a visit to this service. Systems are in place to create an open and inclusive atmosphere, which provides a positive home for people to live in. Staff require training updates in health and safety topics; safe working practices were not always in evidence. EVIDENCE: The manager is registered with the CSCI and has completed NVQ Level 4 in care, and three units of the Registered Manager’s Award, which are needed to meet Standard 31 of the National Minimum Standards. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 25 The manager said that she had attended all the training that she arranged for the rest of staff in order to keep herself up to date with current practice. Staff and residents all said the manager was approachable and had an open door policy. Staff meetings had been held regularly and minutes taken. Staff said that at the meetings they were able to make suggestions about how the service could be developed. Residents asked said there were no residents’ meetings. However, the manager had minuted impromptu meetings she had held with small groups of residents on an informal basis, as she had found that some residents did not always feel comfortable voicing their opinions in formal meetings that had been widely advertised and attended. Satisfaction surveys are sent out at regular intervals throughout the year. Since January 2007, 22 responses from residents and relatives had been received. There was evidence that the manager analysed the surveys and used the comments to make changes to the service. The majority of respondents were satisfied with the care provided. Comments included “Dad is very happy here”, “Visitors are made very welcome”, “my mother is very happy”, “lovely home, staff respect residents and visitors”, “food is of a very high standard”, “the staff are an asset to the home, always on hand to help”, “Dryclough Manor is such a lovely place” and “Mum’s condition has deteriorated and the care is excellent”. Small amounts of money are kept in safekeeping for residents. Ledger sheets are maintained which itemise all transactions and receipts are kept. One resident said she was satisfied with the arrangements at the home for handling her money. Staff said they received an annual appraisal but did not receive regular formal supervision. This was discussed with the manager. Supervision is necessary as a means of determining staff training needs and ensuring staff are aware of the home’s aims and objectives and their part in the delivery of them. The manager said that she had no administrative support and spent time on tasks such as staff payroll and invoicing for fees. It is recommended that an administrator is provided for some hours per week to relieve the manager of some of these tasks so she has more time to fulfil her role with regard to supervision of staff and auditing staff practices and policies and procedures within the home. The maintenance person makes weekly checks of the building and equipment in respect of fire prevention and health and safety. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 26 Two staff were observed using poor practice in relation to moving and handling a resident and although it was reported that equipment, such as handling belts, was available there was no evidence that they were being used by staff. The manager said that moving and handling training, as well as other mandatory health and safety training, such as fire safety, were due and she would be arranging training dates in the near future. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 27 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 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 2 Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 15 Requirement The manager must have in place detailed care plans and risk assessments, which reflect the changing needs of service users and the up to date action required. Full and accurate records of administration of medication must be maintained. (Timescale of 17/09/07 not met). Medication must be administered to residents exactly as prescribed. (Timescale of 17/09/07 not met). Risk assessments must be done for each resident who is self administering medication to make sure they are safe to look after their own medicines, and their health is not at risk. (Timescale of 20/09/07 not met). The practice of secondary dispensing must cease. The practice is high risk and could put residents health at risk. All medication must be ‘in date’ when it is administered to residents to protect their health. DS0000067060.V354612.R01.S.doc Timescale for action 15/01/08 2 OP9 13(2) 31/12/07 3 OP9 13(2) 31/12/07 4 OP9 13(2) 15/01/08 5 OP9 13(2) 31/12/07 6 OP9 13(2) 31/12/07 Dryclough Manor Version 5.2 Page 29 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. 7 Standard OP18 Regulation 37 Requirement Any incident that adversely affects a resident or residents at the home must be reported without delay to the CSCI. All staff must have up to date training in moving and handling and the manager must ensure that staff follow safe working practices when moving residents. All staff must have up to date fire safety training. Timescale for action 15/01/08 8 OP38 13 (5) 30/01/08 9 OP38 23(4) 30/01/08 Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 30 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 OP9 OP12 OP18 OP30 OP36 Good Practice Recommendations The manager should review the storage for medication for residents who are looking after their own medicines. The key worker system should be developed to increase the opportunities to meet the social needs of people living at the home. All staff should attend the “Alerter” training held by Oldham MBC so they are aware of local authority procedures for safe guarding adults. Induction training should meet Skills for Care specifications. Staff should receive formal supervision at least six times per year so that their training needs can be identified and met. Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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 Dryclough Manor DS0000067060.V354612.R01.S.doc Version 5.2 Page 32 - 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. 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