Inspection on 30/10/08 for Flixton Manor

This inspection was carried out on 30th October 2008.

CSCI found this care home to be providing an Good service.

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

Flixton Manor 25/01/08

Flixton Manor 31/08/07

Flixton Manor 27/06/06

Flixton Manor 15/02/06

Flixton Manor 28/12/05

Flixton Manor 15/02/05

Flixton Manor 18/08/04

Flixton Manor 29/03/04

Flixton Manor 16/12/03

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 29/01/2009.

CARE HOMES FOR OLDER PEOPLE Flixton Manor 2-8 Delamere Road Flixton Manchester M41 5QL Lead Inspector Elizabeth Holt Unannounced Inspection 30th October 2008 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 Flixton Manor DS0000006711.V373132.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. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Flixton Manor Address 2-8 Delamere Road Flixton Manchester M41 5QL 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) 0161 746 7175 0161 748 5583 flixtonmanor@msn.com Dr Jan Al Safar Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All service users will fall within the category of old age (60 ). Up to three service users who require personal care may be included within the maximum occupancy. Staffing levels as specified in the Section 25 (3) Notice dated 28th September 2001, shall be maintained. 25th January 2008 Date of last inspection Brief Description of the Service: Flixton Manor is a care home providing nursing care and accommodation for 32 older people. The home had been converted into one residence from two semi-detached houses. Further additions have taken place to enlarge the communal areas and an extension to provide bedroom accommodation. There was a large conservatory at the front elevation of the home that leads into the lounge and dining areas. Access to the home is from the drive and garden. At the end of the drive there is provision for parking. There are concrete steps and a ramp for wheelchair access to the entrance door. The home is situated on the main road between Flixton and Urmston. There was easy access to public transport, local shops and parks. It is convenient for the motorway system. The current scale of charges at the home is £414-plus funded nursing care to £600.00 per week. Costs in addition to the fees are hairdressing; chiropody per visit, newspapers and toiletries, which are charged on an individual, needs basis. Fees can be discussed with the acting manager. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key unannounced inspection, which included a site visit, took place over one day on Thursday 30th October 2008. The manager of the home was not told beforehand of the inspection visit. During the visits we looked at care and medicine records to ensure that the health and care needs of the residents were being met. The time we spent in the home included observing care practices and talking with residents who live at the home, visitors, members of the staff team, the acting manager and the home owners representative who was present during the inspection. A partial tour of the building was conducted and a sample of care and staff records was looked at, including employment and training records, staff duty rotas and resident’s care plans. We sent the manager an Annual Quality Assurance Assessment (AQAA) form before the inspection for her to complete and tell us what they thought they did well and what they need to improve on. We felt there was a shortfall in the information provided in the AQAA and this did not give a clear picture of the home. This was discussed with the manager and the homeowner’s representative during the visit and the manager stated this was because it was the first one she had filled in and she was not aware of the guidance available. We considered the responses and other information gathered during the visit and has referred to this in the report. Nine service user survey forms were completed by residents and their families and one by a staff member and returned to the Commission. The term preferred by the people consulted during the visit was “residents”. This term is, therefore, used throughout the report when referring to those living at the home. Since the last inspection the manager has not yet resubmitted her application to be registered with the CSCI however she said she plans to do this within the next three months now she has gained some further management experience and hopes to have completed the Registered managers award. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection improvements have been made to the information held in the care plans. This makes it easier for the staff to see how they need to support the residents and monitor the care given. Since the last inspection improvements had been made to the environment both internally and externally. This has included repainting of the outside of the home, new windows and guttering. Since the last inspection there have been improvements to the leisure activities made available for the residents to provide stimulation for them. This has lifted the atmosphere in the home and residents spoken to were happy in the environment. Residents were seen to be chatting with each other and some of the residents said, “We do have a laugh and I am happy here.” Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 7 Some of the residents who had been involved in some of the recent social and leisure events expressed their pleasure at this. Improvements have been made to the systems and practices in place to monitor and record the medication practices since the last inspection in January 2008. This makes sure that the residents received the medication they need and shows that the staff are keeping up to date records. Improvements have been made to the mentoring; supervision and induction of new starters at the home to ensure residents are treated in a dignified manner. Since the last inspection the manager continues to inform us of any significant events that have occurred at 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. The summary of this inspection report can be made available in other formats on request. Flixton Manor DS0000006711.V373132.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 Flixton Manor DS0000006711.V373132.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, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with information about the home and have their needs assessed before admission so the individual and the home can be sure the placement is appropriate. EVIDENCE: A Statement of Purpose and Service User Guide was available by the entrance to the home that provides new and existing residents with information about the home. The Annual Quality Assurance Assessment (AQAA) stated that the home was working on developing a brochure and a web site to provide more information for prospective residents. An information package was given to prospective residents and their families to inform them about Flixton Manor. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 10 A review of three pre-admission assessments showed these were detailed; person centred and assessed fully the prospective resident’s needs. The new documentation has been increasingly used since the last inspection and the staff had made more effort to consider the resident’s needs. There were copies of inter agency care plans in place and the information gained from the assessments was used to develop a plan of care following admission. A relative spoken to said she felt fully involved and consulted during the admission process of her relative. Before moving to Flixton Manor residents or relatives may visit to look around the home or spend time at the home before making a decision. One relative said she had found the staff and the atmosphere, “Very homely and friendly when I popped in to look around and I felt it would suit my mother. I believe we were right,” before she made a final decision about Flixton Manor. Flixton Manor does not provide intermediate care facilities. Flixton Manor DS0000006711.V373132.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 good. This judgement has been made using available evidence including a visit to this service. The systems and practices for monitoring the healthcare needs of residents have improved to ensure the health and welfare needs of residents are met. EVIDENCE: Care plans are available for each resident in the home. Since the previous inspection staff members had continued to work hard to use the new documentation to make sure the care plans fully and effectively monitored the care being delivered. Three care plans were looked at as part of the inspection process, which varied in the information provided for the staff to support the residents. The records were generally person centred and showed the staff in a clear way how to support the residents to meet their individual needs. Some further training was required for the staff to see the problems from the persons view rather than using the problem in relation to a medical problem, for example, one care plan talked about diabetes and hypo or hyper glycaemia rather than how the Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 12 staff would support the person appropriately. A discussion with the nurse in charge was held to discuss this. The care plans had a body-mapping tool in place and there were examples of the staff making note of any marks, bruises or changes in a person’s skin condition. Another care plan showed that the resident had a Grade 2 pressure sore on admission. Even though the pain/wound assessment has been filled in and dated the information recorded was confusing. Part of the record keeping described the person’s right heel whereas a discussion with the registered nurse on duty and another record showed it was only the person’s left heel, which had a sore area. One of the care plans looked at did not include the type of pressure relieving equipment being used by the resident and did not state clearly the correct pump setting for the equipment. For another resident the advice from the tissue viability nurse stated that the person should be on a pressure-relieving cushion during the day. The manager advised that the resident had his or her own chair and it was not safe to use the equipment with this chair. A risk assessment should be in place to show the reasons for not taking on board the advice of the professional in line with the risk to the resident. The manager had an audit of the pressure relieving equipment in place and a discussion was held to show this should be recorded in the individual persons care plan. Examples of risk assessments in place included those relating to preventing pressure sores, mobility, moving and handling and nutrition. For residents who had bed rails in place there was no risk assessment process in place. This has the potential to lead to bed rails not being used appropriately. Since the inspection visit the manager has stated she has addressed this concern and has introduced an assessment format in the home for the safe use of bedrails. All residents were registered with a local GP and from the records in place and discussion with the residents it was evident they were encouraged and supported to access opticians, chiropodists, psychiatrists and dentists as needed. Residents and relatives who filled in the survey forms said they were kept informed of all significant changes in their relative’s health and they were satisfied with the care provided. During the visit we looked at a sample of medicine records together with the medicines held by the resident to make sure residents were receiving their medication safely. From the sample looked at we saw that the records were up-to-date and they showed medicines had been given correctly. A sample of controlled drugs were looked at and found to be up to date and records for unwanted medication were appropriately recorded. All the medication administration records included a photograph of each resident to assist staff in the checking process and a record of staff specimen signatures was held. During the last inspection a recommendation was made for a system to be put in place to audit medication and to assess the quality of medication handling and to ensure that the quality of medication handling is assured and residents’ Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 13 health is not at risk. It was seen that thorough recorded checks (audits) by staff are now in place to ensure that both medicines records and stock are accurate. From observations made during the inspection and conversations with staff members, residents and visitors, it appeared the care staff and nurses were respectful and supportive to the residents in the way they spoke to them. One of the resident’s said, “All the staff here are lovely and warm and friendly, they look after us well here.” Resident’s fingernails looked clean and had been attended to and residents spoken to were happy with the care and attention they received. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 14 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. Opportunities exist for residents to maintain contact with family and friends and to pursue some leisure and social activities. The meals at the home offer choice and variety. EVIDENCE: During this inspection it was evident the residents were benefiting from a person dedicated to provide activities and social stimulation who had been employed for approximately four months. A programme of activities and social events was displayed in the lounge area. Activities included arts and painting, bingo, a quiz, exercise classes and one to one activities. Some of the residents were looking forward to a Halloween party they were planning for and they were seen to enjoy making flower arrangements to decorate the tables with. The activities organiser produced the home’s first news and information letter in September 2008, which showed the activities and trips planned in the next few months. One of the residents said she had enjoyed a summer afternoon on the lawn with relatives and she enjoyed the chance to be involved in making things and having something to do. The activities organiser said there Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 15 are plans to have a visitor from a local museum to encourage the residents to reminisce. Many of the residents seemed to be highly dependent and a large number were wheel chair users. Social assessments and histories had been filled in for some of the residents who were case tracked and some information was being recorded about their social needs and how the residents had spent their day. The time residents are brought to the dining tables needs to be reviewed to make sure residents are not sitting waiting for too long. Some of the residents were brought into the lounge at 11.50 and the actual meal was not served until 12.35. This was a lengthy period of time for a number of residents to sit still and particularly for wheelchair users. One resident was seen to slip forward and needed the support of three staff to assist her back into her wheelchair during this period of time, however this was done with caution and ease and involved the use of the hoist. The lunchtime meal was seen to be a sociable occasion in the dining area of the main lounge/conservatory and staff were seen supporting residents in an appropriate way. The tables were pleasantly laid. Residents who could express a view said they were satisfied with the food provided and they felt they got enough to eat. One resident said, “The food is just lovely here, I am satisfied.” The main meal on the day of this visit was cottage pie, or sausages and vegetables and a choice of deserts. Residents said their visitors were always made welcome at the home and one visitor spoken to said, she visited most days and always found everyone very helpful and supportive. All nine surveys stated that residents and or relatives always or usually knew who to speak to if they were not happy. The residents were encouraged to bring in personal items into the home such as photographs, pictures and ornaments. The staff were seen to speak to residents in a friendly way and knew the residents well. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. There is a clear complaints procedure that ensures concerns are appropriately dealt with. Some shortfalls in staff training in safeguarding procedures may lead to residents not being fully protected from harm. EVIDENCE: The home had a complaints procedure and a record of concern/complaints was held by the home. No complaints had been made directly to the service and the Commission for Social Care Inspection had not been in receipt of any complaints about the home since the last inspection. The nine responses to the service user and relative’s surveys showed that they were aware of how to make a complaint and whom they would approach in the home. One resident said that any concerns she had, she felt were listened to and acted upon. From a review of the training records in place some of the staff had undertaken training in the protection of vulnerable adults, however this had not applied to all staff currently employed at the home. Since the visit the manager has made arrangements for abuse awareness training in adult protection for staff who have not yet received this. A copy of the updated Trafford Local procedures on safeguarding was available and the staff had signed to say they had read this. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 17 Two staff members spoken to were aware about how they would act in the event of an allegation of abuse. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 18 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. Residents live in a clean, well-maintained home that was generally comfortable and odour free. EVIDENCE: On the day of the visit the home was clean, tidy and odour free. There is an ongoing programme in place to redecorate the home, which includes the corridors. Since the last inspection new windows have been put in, the outside of the home had been repainted and new external doors had been fitted. Improvements have been made in the basement of the home, this had included painting and decorating. There is a ramp access to the front of the home which allows easy access for wheelchair users and there is plenty of parking at the front of the home. A partial tour of the home was carried out, which showed the resident’s bedrooms, bathrooms and communal areas to be adequately decorated. Some Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 19 areas of the wallpaper in the lounge were looking worn and in need of renewal. There is provision of televisions and music equipment available for residents. The bedrooms looked at showed that they were clean, suitably furnished and personalised. The bedding was clean, fresh and coordinated. Residents who could express a view were pleased with their bedrooms and some residents had personal effects in their room. One resident said she “liked to visit her bedroom sometimes in the afternoon which I do, but a lot of people stay here in the lounge, which is fine by me too.” As raised at the last inspection the manager said the bathroom on the first floor was not used much at all, as residents preferred the shower room. During this visit one resident’s relative said how her only concern was that “my mother has always enjoyed a soak in the bath and there is not the proper facility for her to enjoy this here.” Consideration should be given to upgrading this room to make it comfortable for residents who prefer a bath. Residents had access to a nurse call when they were in bed so they can call for assistance any time they need to. Procedures are in place for infection control practices and the staff were aware of the importance of good hand washing practices. The laundry was clean and organised. On the day of the visit action had been taken to address the dryer which was reported to have broken down. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 20 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 care needs of the residents are met by the number of staff on duty. Shortfalls in the training of staff may lead to resident’s needs not being met in full. EVIDENCE: At the time of the visit the home had 26 residents in receipt of nursing care and personal care only. From observations made during the visit and a review of the duty rotas there appeared to be sufficient staff on duty to meet the care needs of the residents. On the day of the visit there were two registered nurses and four care workers on duty from 7.30am until 8.45pm. Staff spoken to said due to the dependency needs of the residents this worked well unless a staff member was off sick and they were not replaced. Responses to the question, “Are the staff available when you need them?” the residents/relatives surveys showed that three people replied always, three said usually and two sometimes with the following additional comments, “They could do with extra staff on the floor” and “I feel there is not enough staff.” One of the visitors said the staff were generally very busy but they felt their relative was well cared for. Night time staffing levels were one registered nurse and two care workers. A discussion with the manager highlighted that there had been a number of instances of sickness at short notice however this had been addressed. The Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 21 staff commented that they considered that teamwork was generally good at the home and that communication was positive between the staff to make sure the residents received continuity of care. The manager must monitor the staffing levels to ensure they are adequate to meet the resident’s needs. Three staff files were looked at and were all found to contain completed application forms, written references, Enhanced Criminal Record Bureau checks and proof of identification. The files looked at did not contain any photographs of the staff members. This was discussed with the manager who stated that they would address this as a priority with the digital camera. A requirement made at the last inspection was met with appropriate recruitment procedures being followed including appropriate referees and completed application forms. The manager reported in the AQAA that 35 of care staff at the home had successfully completed or were working towards National Vocational Qualification Level 2 training. The manager is advised to encourage more staff to undertake this training. There was evidence that staff had some access to training courses. Available records showed that nineteen staff had received fire safety training, several staff members had received moving and handling training, one nurse had undertaken some training in diabetes, Mental Capacity Act and infection control. Staff have not recently been updated in challenging behaviour however one of the residents presented with behaviour that was challenging to themselves. None of the laundry or domestic staff had received training in the Control of Substances Hazardous to Health. The manager stated she had found this difficult to access but would continue to look. Further training is recommended to ensure that all staff have the necessary skills and knowledge to meet the needs of the residents. It is advisable for the manager to keep a training matrix for staff to be able to see at a glance what training has been undertaken and what training was planned. Staff spoken to said they enjoyed undertaking courses because they believed it helped them in their daily work to care for the residents. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 22 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to ensure the standards and practices in the home promote and safeguard the health, safety and welfare of the residents living there. EVIDENCE: The acting manager stated she plans to resubmit her application to register with the CSCI when she has completed the registered managers award and has gained more managerial experience. The clinical lead nurse has supported the manager in clinical areas of the home. Comments from the staff were positive in terms of how the manager and the clinical lead nurse are moving the home forward, however the manager needs more guidance and support to address the areas identified in this report. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 23 Since the last inspection a review of the accident records showed that a system was in place to audit these since the last inspection and if any necessary strategies could be put in place to minimise the risk to the residents. Mrs Simcock showed a good knowledge of the residents and it was pleasing to see that the experienced nurse has continued to lead on the clinical needs of the residents. Residents and relatives spoken to said the manager was approachable and that she did listen to suggestions and any comments made. The manager said that surveys had been sent out to residents and their relatives to obtain feedback about how the service seeks the views of residents and relatives. The responses had been minimal however the manager stated she listened to views of residents and relatives. The AQAA stated that the home acts on feedback and seeks the views of residents. Evidence was seen of the passenger lift and the hoist being serviced. A fire risk assessment had been carried out. Records were seen of checks of fire equipment, means of escape, fire alarms and fire drills. Information provided in the AQAA highlighted that tests or servicing of the electrical circuits and the heating system were not currently in place. The manager has since confirmed these tests have been completed but the AQAA was not fully completed. A sample of personal allowances were looked at which were held securely at the home. A record was held of monies paid out to residents and receipts were held for transactions made. Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 25 yes Are there any outstanding requirements from the last inspection? 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 OP31 Regulation Section 11 Care Standards 2000 Requirement The home must put forward an appropriately experienced person to manage the care home to ensure the health and welfare of the residents are promoted and protected. (Previous timescale of 30/04/08 not met). Evidence must be provided that staff have undertaken the necessary training to ensure that it provides suitably qualified, competent and experienced staff to ensure the health and welfare needs of the residents are met. Timescale for action 30/01/09 2. OP28 18(1)a 30/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 26 1. 2. 3. OP7 OP21 OP18 It is recommended that the care plans show clearly how the staff actually support the residents to meet their needs and maintain their health and well being. It is recommended that the bathroom on the first floor is upgraded to make this acceptable for residents who prefer a bath. It is recommended the manager monitors the staffing levels to ensure they are adequate to meet the resident’s needs. It is recommended the acting manager is supported and guided appropriately to manage the care home in the best interests of the residents. 4. OP31 Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road 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 Flixton Manor DS0000006711.V373132.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!