Inspection on 08/05/06 for Finch Manor

This inspection was carried out on 8th 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

Finch Manor 21/01/09

Finch Manor 03/04/08

Finch Manor 25/10/07

Finch Manor 02/11/06

Finch Manor 02/02/06

Finch Manor 27/07/05

Finch Manor 21/01/05

Finch Manor 19/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Finch Manor Finch Lea Drive Dovecot Liverpool Merseyside L14 9QN Lead Inspector Les Smith Key Unannounced Inspection 8th May 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 Finch Manor DS0000048861.V288033.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. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Finch Manor Address Finch Lea Drive Dovecot Liverpool Merseyside L14 9QN 0151 259 0617 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) Moorshield Ltd Mrs Julie Archer-Moran Care Home 89 Category(ies) of Dementia - over 65 years of age (54), Old age, registration, with number not falling within any other category (35) of places Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service should at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. A maximum of 89 older people may be accommodated of whom no more than 75 shall be in the category DE (E) and 14 in the category of OP. To accommodate four service users aged 55 to 65 years old on DE (E) unit 2nd February 2006 Date of last inspection Brief Description of the Service: Finch Manor is a purpose built, single storey home situated in the Dovecot area of Liverpool. It is set in its own grounds with gardens to the front and rear and with two internal courtyard-sitting areas. The home provides care and support in four units. One with 14 places is for the general care and support of older people. Another has 21 places for older people with dementia who require personal care only and the remaining 54 places are across 2 units provide nursing care and support to older people with dementia. All of the residents accommodation is provided in single bedrooms with en-suite WC and wash hand-basin. A full range of aids and equipment is available providing assisted showers and baths and all areas of the home are accessible by wheelchair. Lounge and dining areas are located in each of the units and a central kitchen prepares food that is delivered in hot cupboards for care staff to serve to residents. An internal security system of keypads on connecting doors prevents residents from wandering out of the home or between units. Fees at the home range from £307 to £469 depending upon category. The home is within walking distance of local shops and there are public transport routes nearby. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days for a total of 18 hours. The inspector examined care records and associated documents, staff files, management records and had discussions with staff of all grades, residents and visitors to the home. All residents and relatives spoken to were happy with the service provided. A total of 38 questionnaires were sent out to relatives and 18 responses were received. The home has recently been through a period of managerial instability and the previous manager had just returned to the home and been in post for one week at the time of inspection. Responses to questionnaires sent to a random selection of relatives / representatives of residents 1 2 Have you received a contract Did you have enough information about the home before you moved in Do you receive the care and support you need Do staff listen and act on what you say Are staff available when you need them Do you receive the medical support you need Are there activities arranged by the home that you can take part in Do you like the meals at the home Do you know who to speak to if you are not happy Do you know how to make a complaint Is the home fresh and clean Yes 10 14 Always 10 12 10 14 5 8 12 13 11 No 8 4 Usually 7 4 7 4 5 5 1 4 6 Sometimes 1 2 1 6 5 4 1 1 Never 3 4 5 6 7 8 9 10 11 2 What the service does well: Finch Manor provides a homely, safe and comfortable environment with all rooms having ensuite facilities and residents positively encouraged to personalise their rooms and a good level of care provided by a well motivated work force. The activities programme continues to develop and provides the opportunity for social interaction on both group and a one to one basis with residents positively encouraged to exercise their own choice whenever possible in many aspects of their daily lives. Concerns expressed by residents or their representatives are addressed in a timely and effective manner promoting a positive atmosphere throughout the home. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 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 Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 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): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives can be confident that their needs will be fully assessed but cannot always be confident that those needs and aspirations can be met in order to enable them to maximise their potential for the best quality of life. EVIDENCE: Finch Manor has a combined Statement of Purpose and Service Users Guide. The document is well-presented, easy to read and contains all the required elements. Copies of the document are given to all residents or their representative on admission and is available to prospective residents when assessing the home for suitability before making a decision as to whether to accept a place at the home. The document is displayed in a prominent place and available for occasional visitors to read and request a copy if they wish. Four (22 ) of respondents to the questionnaire stated that they did not have sufficient information about the home before accepting a place with two respondents providing additional information that they were placed under pressure by hospital staff to find a place quickly. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 9 Contracts for self-funding residents are sent out by the head office for signing and return to the home. Statements of Terms and Conditions for funded residents are signed on admission and copies of these were seen. However two files examined had no contract or Statement of Terms and Conditions and 44 of the questionnaires returned stated that no contract had been received. A selection of care files including residents with identified sensory impairment and communication difficulties were examined on the day of inspection and all included a detailed pre-admission assessment document. The homes manager or senior nurse completed the pre-admission assessments which included details of nursing and personal care needs together with cognitive ability, challenging behavioural and social problems. The information gathered was appropriate in quantity and quality to enable construction of an initial care plan. The home has all the appropriate equipment and facilities to meet residents’ needs. Equipment and aids provided by the home include assisted baths and shower rooms, toilet adaptions such as raised toilet seats, hoists and slings and slide sheets for transferring and moving residents comfortably and safely. Wheelchair access is available to all areas of the home including the garden areas. Evidence was seen that the services and expertise of the multidisciplinary team was not always utilised when required. Two of the trained nurses are currently working towards the N11 qualification to obtain the additional knowledge and skills to enable them to care for and support older people with dementia. One carer spoken to has been at the home for five years but has received no training in dementia or challenging behaviour. Examination of the training records show that out of 69 staff only 20 have received training in caring for residents with dementia and 16 having had training in challenging behaviour. Progress has been made in relation to establishing a distinct residential unit and two nursing units for residents with dementia thereby enabling the differing needs and aspirations of the two client groups to be met more appropriately and the process of reassessment and consolidation is continuing. Visitors and prospective residents are encouraged to visit the home at any time and as often as they wish when deciding whether to request or accept a place at the home. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 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): 7,8,9,10,11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents health, personal and social care needs are not always identified or recorded in a plan of care and consequently failing to be met. Medication management fails to meet statutory requirements and current good practice guidelines placing residents at risk of harm or injury. Residents are treated with respect and the right to privacy is upheld at all times. EVIDENCE: A range of care plans and associated documentation were examined on the day of inspection. These included residents with differing needs such as sensory impairment, specialist nursing needs and varying levels of cognitive ability. The care planning process is neither comprehensive nor consistent. Lack of one or more required care plans was noted in most care files. The care plans that were not present ranged from basic to complex needs. The lack of required care plans fails to demonstrate that the interventions to meet known needs have been put in place. The risk of required care not being given due to lack of appropriate care plans is not acceptable. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 11 The standard of regular care plan review was variable ranging from a detailed evaluation of care to an inadequate statement such as ‘no change to care plan’ with no justification as to why the care plan was to continue. The regular evaluation of care plans is essential to monitor the effectiveness of the care delivered and therefore the evaluation must detail the effectiveness or otherwise of care delivered thereby justifying any changes or no change to the plan. Daily report sheets were completed in variable amounts of detail. Some members of staff record a good level of detail whilst others record non-specific comments such as “settled and slept well”, “satisfactory morning”, appears bright”, and “no change”. Statements such as these give no indication as to the actual care delivered, the outcome of that care or how the resident has spent their day. The promotion of independence invariably involves an element of risk, which is managed via the completion of relevant risk assessments. The required risk assessments were not always present in the care files examined. Where risk assessments were present and reviewed, examination showed that the reviews did not always reflect changes, which were evidenced in other parts of the care file. Associated documentation such as fluid and repositioning charts is poorly maintained and does not demonstrate the level of care given. The associated care documentation provides the evidence that relevant care interventions have been carried out and accurate record keeping is essential. Examination of wound management records showed that information was minimal with no record of wound mapping, size, exudates or dressing type available. Full mapping of sores must be undertaken to ensure that improvements and deteriorations can be identified in the early stages to further plan the treatment to be given. Residents identified as having sensory impairment had no plans in place to address their special needs and plans in relation to their activities of daily living failed to reflect the additional input and care required due to their sensory impairment. Documentation in several care files showed that concerns in relation to aspects of care had been identified e.g. loss of weight, but no appropriate changes to care had been made nor had any referrals been made for specialist advice from available services e.g. dietician. The variable standard of care planning is a cause for concern given that the poorest standards were observed on the nursing units were care plans are constructed and maintained by trained staff and it is in these areas were residents have the more complex needs. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 12 The findings in relation to care planning are supported by the responses to the questionnaire sent to relatives and residents that showed that only 55 felt they always received the care and support they needed and 77 felt they always received the medical support required. Medication Examination of the Medication Administration Record (MAR) sheets showed gaps in the signatures confirming administration. Two members of staff did not sign handwritten scripts for items prescribed and received between the monthly cycles. Temperatures for drug fridges were not always recorded and the temperature of the clinical room was not recorded at all. The process for ordering and checking of medications into the home fails to ensure that prescribed medications are always available for residents. The new monthly cycle for medications commenced on the first day of the inspection. Were medications had not been delivered the inspector asked the nurse in charge whether the medication had been discontinued but the nurse did not know. Further enquiries established that in some cases the medication had been discontinued but in other cases it was still prescribed but failure to receive the drug resulted in the medication not being given. The MAR sheet must be an accurate record of prescribed medications as the consequence of this not being the case places the resident at high risk of drug error either by misadministration or omission. One large cardboard box and three black bags of unwanted medications were found in treatment rooms which had not been disposed of in accordance with the homes policy and statutory requirements. Residents or their representatives were very positive when spoken to in terms of the respect shown to the residents and the steps taken to ensure that privacy is maintained at all times. Staff members were observed interacting with the residents in a manner that respected their dignity and always addressed residents appropriately. Residents were all dressed appropriately in their own clothes and all personal care was always be carried out in private. Finch Manor DS0000048861.V288033.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. As far as possible residents have choice and flexibility in how they spend their day in the home, and participate in leisure and recreational activities according to their choice and preferences thereby promoting independence and individuality for each resident. Meals at Finch Manor are good, offering a limited choice and variety whilst catering for residents’ dietary needs or cultural preferences EVIDENCE: Finch Manor employs two full time activity co-ordinators who provide a range of activities including one to one activities for those residents who cannot or do not wish to take part in group activities. On the day of inspection one resident was having a birthday party and the inspector observed arts and crafts, word games and some reminiscence activities being enjoyed. The residents in the general residential unit enjoy their regular bingo sessions and complain strongly should it for any reason be cancelled. The recording of activities participation in the care file has commenced and plans are in place for families to be requested to complete life histories so that activities may be more specifically identified in line with residents’ preferences. The availability of activities is a personal perception and the questionnaire results show that only Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 14 55 of respondents felt that activities were either always or usually available and this indicates that extra effort is required to secure a more inclusive participation in activities. Visitors are welcome at the home at any time and evidence of this was seen with visitors arriving at the home from early morning. Visitors are requested to liaise with the home if they wish to make a late evening visit for security reasons. The opportunity for making decisions and exercising choice in many aspects of daily life is limited for the majority of residents assessed as having impaired cognitive ability but staff are encouraged to promote choice wherever possible e.g. choosing a set of clothes for the day. The home provides details of the CareAware advocacy services and leaflets are freely available throughout the home. The menus have recently been altered and the choice and variety has decreased. However the new manager is aware of this and is addressing the situation and menus will be restructured over a four-week cycle and provide an alternative choice at main meal times as well as a greater variety. Finch Manor DS0000048861.V288033.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): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families may be certain that complaints are taken seriously and will be acted upon in a timely and effective manner and those residents are protected from any form of abuse. EVIDENCE: There is an appropriate policy and procedure in place in place for the management of complaints and the procedure is included in the Service Users Guide and displayed in a prominent place at the home. Relevant forms to make a complaint are readily available in the main reception area of the home. The ongoing allegations of abuse have been resolved and resulted in two residents leaving the home, one as a result of re-assessment of care required and one at the request of family. One RGN has left the home without disciplinary action and a carer has been dismissed and referred to the POVA list. One recent complaint concerned the external hairdresser and a satisfactory resolution has not been achieved despite extensive efforts by the homes management and the family have now removed the resident to another home. The CSCI has received three anonymous complaints in relation to the previous management at the home, which have been resolved. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 16 Relatives spoken to during the inspection stated that the return of the previous manager has restored their confidence in the management of the home and that any concerns that they may have will be dealt with in a timely and effective manner All residents are registered on the electoral roll albeit very few are able to exercise their legal right to vote. The home has provided training to staff in the various types of abuse, their recognition and the procedures to follow whenever abuse is suspected. Examination of the homes training schedule show that 75 of staff have now received this training and it is ongoing. All members of staff spoken to had a good understanding of abuse, its’ various types and recognition of abuse and the correct procedures to follow. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 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): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of décor and furnishings within this home has improved significantly and now provides residents with a homely, comfortable and safe environment to live EVIDENCE: A tour of the home was undertaken accompanied by the home manager. A major redecorating and refurbishment programme is now in place and ongoing. Rooms are being redecorated and refurbished at a rate of two per month. All rooms have been reviewed and prioritised taking into account soft furnishings and floor coverings as well as the décor. All the corridor carpets are in the process of being replaced. Armchairs for the communal areas are being replaced at the rate of six per month. Over bed tables in rooms and communal areas were seen to be damaged or with trim missing. These need to be replaced or repaired as soon as possible and the manager stated that this would be done. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 18 The kitchen fridge in one of the nursing units was broken and needs replacement as do the kitchen cupboards which are also broken. All inappropriate items stored in bathrooms and toiletries have been removed and all bathrooms and toilet facilities were clean and fresh. Residents and relatives spoken to all expressed their satisfaction with individual rooms and were pleased that the redecoration programme had commenced. Rooms seen were tidy and well presented with most showing personalisation with residents’ own pictures and other items. The tour included the laundry and kitchen and both areas were clean and well organised. New trolleys had been provided in the kitchen and a new rotary ironer in the laundry has made a big improvement. The standard of cleanliness throughout the home has improved and on the day of inspection was exceptionally clean, pleasant and hygienic. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 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): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is insufficient care staff employed to meet the assessed needs of residents which places residents at risk of harm or injury. Residents are supported and protected by a robust recruitment policy EVIDENCE: Examination of off duties showed that staffing is not sufficient to meet the assessed needs of the residents. Concerns in relation to staffing levels have also been expressed by the commissioning authority following a recent contract-monitoring visit. Current staffing levels were noted to be: Morning Afternoon Night 2-trained plus 10 care assistants 2-trained plus 9 care assistants 2-trained plus 8 care assistants The increasing dependency and complexity of assessed needs of residents in all areas of residential care is an established and continuing trend. The care and support required by a resident with dementia increases over the course of a day with a peak usually in the early evening. It is not acceptable for staff levels to be reduced from 1400 hrs as currently happens. The shortage of staff is supported by a variety of evidence. There have been 74 accidents/falls in the first four months of the year. The lack of robustness in the care planning process and the failure to identify and meet care needs is in Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 20 part due to the shortage of staff and responses to the questionnaire sent to relatives and residents showed that only 55 felt they always received the care and support they needed and 77 felt they always received the medical support required. Discussions have taken place with the manager and operations manager and an urgent review is being undertaken with the manager and operations manager being aware of what would be considered the minimum level of staff required. Examination of the staff records and training schedule shows that 6.4 of all staff members have NVQ 2 with 12.8 having NVQ 3. The percentage of care staff with NVQ 2 or equivalent is 41 .8 , which falls short of the 50 standard. The manager informed the inspector that recommencement of the NVQ programme was one of her priorities and that all ancillary staff would also be encouraged to obtain the appropriate NVQ qualification for their area of work. Training records showed that whilst mandatory training was up to date there was little specialised training e.g. caring for stroke patients, diabetes, dementia care and the inspector was told as with the NVQ programme this is being addressed by the new manager. A selection of staff personnel files including recent starters were examined and found to contain all of the required documents demonstrating that the recruitment process is now robust. New staff members serve a probationary period and confirmation of a permanent post is only given following satisfactory completion of this period. Evidence was seen that new staff receives an appropriate TOPPS compliant induction. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 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): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The newly appointed manager is able to provide the leadership and guidance required to promote and protect the health, safety and welfare of residents and manage the home in their best interests. EVIDENCE: The newly appointed manager was previously at Finch manor up to the end of 2005 and has returned to the home. Appropriately qualified and experienced the manager has a proven track record and although only in post for one week at the time of inspection had already made a significant positive impact. The manager has a clear vision and sense of direction and her management style is open and transparent as evidenced in conversations with staff and relatives whilst maintaining a focus on managing the home in the best interests of residents. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 22 The operations manager makes regular monthly, unannounced visits and submits detailed reports of his findings to head office, the home manager and the CSCI. A definitive quality assurance system is not yet in place at the home but the manager demonstrated details of the processes which are planned based on the components of care 2006 a research based model of self assessment. Policies and procedures are regularly reviewed and the organisation keeps abreast of legislation changes and initiates the reviews. There is a need to promote the involvement and views of residents, their families or representatives and other health care professionals who use the service at Finch Manor. Residents’ monies are held at head office and requests are made via the home manager if funds are required at home level. Records in relation to these monies must be kept at the home in order that they are available for inspection at any time. Formal supervision of staff is carried out at the home and although this has fallen behind due to the period of managerial instability the homes manager has recommenced supervision covering the required elements and at the appropriate time intervals. Both home and individual records are securely stored and in good order, stored securely and used in accordance with the Data Protection Act 1998 thereby promoting and protecting the health, safety and welfare of both residents and staff. Fire alarm and emergency lighting checks are appropriately done and recorded. COSHH assessments had been undertaken and cleaning materials were stored in an appropriate place. On the day of this inspection the home was displaying a valid public liability certificate in a prominent place. All relevant safety certificates for Gas, Electricity, portable appliance tests and hoists were seen and were found to be valid. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 23 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 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 2 3 3 3 Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 24 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 OP2 Regulation 5 Requirement The registered person must ensure that each resident is provided with a Statement of terms and Conditions or Contract The Registered provider must ensure that all staff have completed or undertake the appropriate training and/or qualifications to gain the knowledge and skills necessary to care for and support residents with dementia. The registered person must ensure that all patients care plans are kept up to date and reflective of the assessed needs, care required, care delivered, and all recordings in the care notes are in accordance with current good practice guidelines. Timescale for action 31/07/06 2 OP4 18(1)(a) 31/08/06 3 OP7 15 31/07/06 4 OP8 13(1)(b) The registered person shall make 30/06/06 arrangement for service users to receive where necessary, treatment advice and other services from any health care professional DS0000048861.V288033.R01.S.doc Version 5.1 Page 25 Finch Manor 5 OP8 17 6 OP9 13(2) The registered person must 30/06/06 ensure that records are kept in relation to: 1: any nursing provided to the service user incl. a record of condition and any treatment or surgical intervention 2: details of any plan relating to the service user in respect of medication, nursing, specialist health care or nutrition 3: a record of incidence of pressure sores and of treatment provided to the service user The registered person must 09/05/06 ensure that prescribed medications are available for administration at all times. (This requirement was issued on 09/05/06) 09/05/06 The registered person must ensure that the receipt, storage, administration and disposal of medications meet the requirements of the Medicines Act 1968 and The Royal Pharmaceutical Society guidelines for administration and control of medicines in Care homes. (This requirement was issued on 09/05/06) The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of service users. The registered person must establish and maintain a system for reviewing at appropriate intervals; and improving the quality of care provided at the home including the quality of nursing. DS0000048861.V288033.R01.S.doc 7 OP9 13(2) 8 OP27 18(1)(a) 30/06/06 9 OP33 24(1)(2)(3) 31/08/06 Finch Manor Version 5.1 Page 26 10 OP35 20(1)(a)(b) 11 OP35 17(2) 12 OP35 17(3) The registered person shall not 30/06/06 pay money belonging to any service user into a bank account unless: a) the account is in the name of the service user, or any of the service users, to which the money belongs b) the account is not used by the registered person in connection with the carrying on or management of the care home The registered person must 30/06/06 ensure that a record of all money or other valuables deposited by the service user for safekeeping or received on the service users behalf, which – a) shall state the date on which the money or valuables were returned to a service user or used at the request of the service user, on his behalf and where applicable, the purpose for which the money or valuables were used: and b) shall include the written acknowledgement of the return of the money or valuables. 30/06/06 The registered person shall ensure that the records in relation to service users money or valuables are: a) are kept up to date; and b) are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the home. Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations It is strongly recommended that the registered person consider a review of registration details to clearly identify the number of places available in each of the categories It is recommended that a mechanism be put in place to ensure that contracts are signed and returned to the home It is strongly recommended that all staff including ancillary be facilitated to undertake relevant NVQ qualifications 2 3 OP2 OP28 Finch Manor DS0000048861.V288033.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. 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