Inspection on 22/01/06 for Hope Manor

This inspection was carried out on 22nd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hope Manor 15/01/09

Hope Manor 23/01/08

Hope Manor 22/07/06

Hope Manor 19/11/05

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hope Manor 220 Eccles Old Road Salford Gtr Manchester M6 8AL Lead Inspector Sylvia Brown Unannounced Inspection 22nd January 2006 13:30 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 Hope Manor DS0000063856.V278557.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. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hope Manor Address 220 Eccles Old Road Salford Gtr Manchester M6 8AL 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 788 7121 0161 788 7121 Coveleaf Ltd Mrs Christine Beasley Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 24 older people (OP) requiring personal care only may be accommodated. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Dependency levels of service users must be assessed on a continuous basis and staffing levels adjusted appropriately to ensure continued compliance with the minimum levels set out in the Residential Forum Guidelines, `Care Staffing in Care Homes for Older People`. 19th November 2005 Date of last inspection Brief Description of the Service: Hope Manor is a 24 bed, privately run home for older people, providing personal care. The home is registered in the name of Coveleaf Ltd. The home is situated in a residential area of Salford on a busy main route and within close proximity to Hope Hospital. The home is accessible by public transport and major motor routes, such as the Manchester Ring Road. Parking facilities are available to the front of the house. The home is close to local shops, shopping areas, such as Salford City precinct, and other public amenities. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Hope Manor was conducted on a Sunday, commencing at 1:30pm, with a total of six hours spent on the premises. Time was spent sitting and talking with residents and visitors. The primary focus of this inspection was to monitor the home’s progress in meeting requirements and recommendations made at the last inspection and ensure that all the core standards have been evaluated within the inspection year. During the inspection the registered manager visited the home to assist the inspection. In addition to speaking with five residents, the inspector was able to observe staff practices as they completed their duties and evaluate a sample of records and parts of the building. Comment cards were provided to residents and visitors and of these, nine were returned by residents and two by relatives. Where applicable and relevant, comments made are included within the report. What the service does well: What has improved since the last inspection? What they could do better: The home’s administration systems continue to require development to ensure that care plans, assessment, reviews and records are all up to date and accurately reflect the current needs of residents. Medication records and administration procedures continued to be below the required standard. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 6 Staffing levels were not sufficient to meet the needs and demands of the home, and duty rotas required further information in relation to hours worked, what position and who by. Staff require appropriate formal supervision and recruitment and selection procedures were below the required standard. The registered manager is required to complete NVQ training in a timely manner and some staff are required to complete adult protection training Quality assurance procedures remain outstanding, as are Regulation 26 visits, both of which ensure residents and relatives are consulted and which enable the home to objectively evaluate the services they offer. 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. Hope Manor DS0000063856.V278557.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 Hope Manor DS0000063856.V278557.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): 4. Standard 6 is not applicable to Hope Manor. The home was not able to fully demonstrate that it could meet the assessed needs of residents, specifically those with dementia and/or mental health. EVIDENCE: The previous inspection identified that a number of residents appeared to have behaviour associated with dementia and/or mental health. The home’s registration certificate does not identify the home being registered to care for such dependent residents and, consequently, the home was required to apply for a variation to its registration. The registered manager stated that the registered owners have consulted with the CSCI regarding this matter and as the residents in question were accommodated prior to the onset of the conditions, a variation is not required. Observations at the current inspection identified that the residents with complex and/or difficult behaviour are, in the main, well looked after in respect of their personal care. However, care staff are not all trained in managing difficult behaviour associated with dementia and mental health. Furthermore, there were insufficient staff on duty to care and supervise those with more complex needs. During the afternoon, one resident was agitated and wanted Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 9 to wander, whilst in the early evening, another resident was restless and fractious at times. Had it not been for the registered manager, who came on duty to facilitate the inspection, it is not known how this resident would have been managed as the remaining care staff cared for other residents. Records failed to identify that statutory reviews were up to date or that up to date assessments had been completed for those residents who may have mental health conditions. During the inspection visitors were evident within the home. One family informed the inspector that they were very pleased with the services of Hope Manor and that they were always made to feel welcome. One comment card received from a visitor stated ‘I am very satisfied with the running of the home’. Hope Manor DS0000063856.V278557.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 Residents’ written care plans failed to contain all the required information. EVIDENCE: The registered manager has commenced developing care plans to meet the required standard. Although not all were fully completed, new care plans were observed and found to have improved. However, they continue to require further development to ensure that they contain all the required information about the individual’s care needs and how they should be met, including oral health in place. It was evident that risk assessments undertaken by relevant professional bodies were not in place, particularly for those that expressed signs of dementia and/or mental health. One care plan detailed ‘prone to mood swings’; on another ‘disturbed behaviour’ was recorded. Nonetheless, there was insufficient information to indicate how these behaviour patterns affected the resident, how they should be managed or if any specific care practice was required. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 11 Evaluation of care plans also failed to demonstrate that residents or their families had viewed their individual care plan and agreed to the current assessments and support provision in place. Doctors’ visits are recorded, as are other health visits. All nine comment cards from residents stated they felt well cared for and, at the inspection, such comments as ‘smashing’ and ‘cared for lovely’ were made by residents. Furthermore relatives spoke at length about their satisfaction with the care support provided by the home. During administration of medication the administrator was observed to handle medication by hand without hand washing procedures or protective gloves being worn. Such practice is incorrect and can increase the risk of crossinfection and cause harm to the resident. Signature omissions were evident for medication administered and unclear records were evident for the administration of Warfarin for one resident. The home does not have systems in place to routinely monitor medication practices and evaluate staff’s competence when administering medication. Residents’ clothing was observed to be clean and well maintained, time had been spent ensuring residents’ hair was styled and that the ladies wore, where preferred, jewellery and accessorises. The gentlemen were clean-shaven and wearing appropriate clothing which reflected their own personality and preference. Staff were observed talking to and supporting residents in a dignified and respectful manner. Comment cards received confirmed observations made, in that, all residents stated their ‘privacy was respected’ and that they felt they were ‘treated well’ Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 12 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 Residents are supported to make choices and decision and are able to receive visitors as they wish, with the home providing residents with structured daily activities. EVIDENCE: When asked about the activities provided in the home, the registered manager explained that daily arrangements were flexible rather than structured. The home provides external entertainment in the form of weekly exercise classes and social events. Unfortunately, the home does not maintain a record of social provision and daily records failed to identify any activities undertaken by individuals, therefore it cannot be concluded that residents live in a stimulating environment and are offered sufficient opportunities to socialise. Eight of the nine comment cards returned by residents stated that the home provided suitable activities for them. Notwithstanding, requirements have been made regarding consultation with residents in respect of activities and ensuring that residents receive appropriate stimulation and socialisation. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 13 One resident spoken to stated ‘I do my own thing’. She explained that the home ensures she receives library services and that she has a good variety of interesting books from which to choose. Other residents were observed sitting in their rooms rather than being seated in the communal parts, they appeared happy and contented and stated their satisfaction at being able to choose where they wished to sit. Throughout the inspection visitors were observed within the home, sat in communal and private rooms. It was apparent that they felt at ease and had formed positive relationships with staff, culminating in visits being relaxed and friendly. The inspector advises the registered manager to seek ways in which to encourage visitors to visit in private, rather than sitting in the communal areas which may, at times, be distracting for some, particularly as they relax and enjoy watching television. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 14 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 The home has an effective complaints procedure in place, which is known to residents and relatives. Although Adult Protection procedures are in place, not all staff have completed adult protection training, which has the potential to compromise residents’ safety. EVIDENCE: The registered manager stated that the home has not received any complaints since the previous inspection. She further stated that she has, in preparation, completed new recording formats to ensure that when complaints are received, they detail the nature of the complaint, the action taken to investigate and outcome, including any action required to prevent reoccurrence. Comment cards confirm that residents and relatives were aware of the complaints procedure. The requirement made at the last inspection to ensure all staff were trained in adult protection procedures has been partially met, with some staff having completed training with others awaiting a place on the next training. The requirement will continue until all staff have received training. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 15 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 & 22 The home is comfortable and safe for residents although some upgrading is required in respect of lighting and armchairs. EVIDENCE: Since the last inspection, the registered manager has taken action to safeguard residents, in that, glazing to doors where it cannot be identified as safety glass has been fitted with a protective coating. The registered manager advises this is a temporary measure whilst discussion continues about replacement doors or glazing. The recommendation made in respect of providing a loop system in the home is still being considered. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 16 During the inspection the home was clean and warm. Side lighting ensures the home looks ‘cosy’ in the evening, however one resident did mention to the inspector that main lighting did not help them see when reading. The main lights currently used had small low wattage bulbs without shade. This fails to provide sufficient main lighting for residents and detracts from the homely environment. Armchairs were also showing signs of general wear and tear, in that, arms were dirty and marked. A recommendation was made that chairs and seating are assessed and, where identified, cleaned or replaced in order to ensure that the homely ‘cared’ for environment does not further deteriorate. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 17 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 The home is not sufficiently staffed to meet the needs, numbers and requirements of the residents and the recruitment and vetting of staff had the potential to place residents at risk. There were also some practices which placed residents at risk. EVIDENCE: The duty rota identified that at weekends the home has two members of staff on duty between 4:30pm and 9:30pm. This ratio falls short of the minimum ratio required and most certainly does not equate to the amount of staff required when taking into consideration the layout of the building and the assessed needs of residents. The inspector was informed that approximately six or seven residents required two care staff to assist with mobility. The inspector also observed at least two residents who required specific monitoring due to conditions associated with mental health or dementia. One resident had to be supported by the registered manager for some considerable time to ensure her safety whilst staff attended to others. The registered manager explained that the home was short staffed and that she was always on 24 hour call out. The rota failed to identify when the manager had been called out to support the staff. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 18 The rota also identified an occasion when only three staff were on duty from 7:30am until 1:30pm. This is below the required staffing level, as peak periods, i.e., mornings and mealtimes, should demonstrate additional staff to meet the rising routines of residents and support required at mealtimes. It was also noted that the home does not routinely have a cook on duty or domestic support at weekends. The rota failed to identify who undertook these duties and when. The registered manager stated that it was her understanding that the home had agreed such staffing levels with the CSCI. However, the home’s conditions of registration detailed on the home’s certificate of registration state: ‘Dependency levels of service users must be assessed on a continuous basis and staffing levels adjusted appropriately to ensure continued compliance with the minimum levels set out in the Residential Forum Guidelines, Care Staffing in Care Homes for Older People’. The home continues with the promotion of NVQ training, with one staff completing training at level 2 since the last inspection. Three staff are awaiting commencement of NVQ level 2 training with the registered manager and deputy attending a workshop prior to the commencement of NVQ level 4 training. The inspector evaluated two staff files. One file, for a recently employed staff member, failed to contain a current photograph, proof of identity, CRB check, references or the interview process. The registered manager explained that the member of staff had worked at the home previously. There was no indication as to why the staff member had left, or exploration of work undertaken since leaving. The home could not evidence induction processes, supervision or if the employee had been informed of or received information regarding the code of conduct set by the General Social Care Council (GSCC). The second file failed to contain a current photograph, CRB, induction, contract of employment or supervision records. The previous inspection identified that the home failed to demonstrate that it recruited and selected staff in accordance with Regulation 19 and Schedule 2 of The Care Homes Regulations 2001 and National Minimum Standards 29, 30 and 36. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 & 38 The home is, in the main, well managed with health and safety procedures and checks in place. However, the home’s policies and procedures relating to the vetting of staff was not being managed well. The registered manager has yet to complete required training and staff require formal supervision. EVIDENCE: The registered manager achieved registration with the CSCI as a fit person to run and manage a care home in July 2005. A condition of the home’s registration, and identified on their registration certificate, is that the home should have a suitably qualified manager in place. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 20 At the time of the inspection it was evident that the registered manager was not qualified to the required standard. She informed the inspector that she was awaiting commencement of NVQ training and had planned to attend a workshop regarding such training. A requirement has been made regarding a timeframe within which the CSCI requires the manager to achieve NVQ Level 4 and Registered Manager’s Award. Notwithstanding the above information, the registered manager has consistently presented herself as caring and committed to the running of the home for the benefit of residents. One resident’s comment card stated they were ‘quite satisfied and everyone is helpful’. Another stated ‘its like living in a hotel’. All returned comment cards stated residents felt well cared for and safe. Quality assurance procedures were not undertaken to the standard required by Regulation 24 of The Care Homes Regulations 2001 and Standard 33 of National Minimum Standards. Though the registered owner frequently visit the home, they do not currently undertake statutory Regulation 26 visits which formally monitors the home’s conduct in both practice and administration and consults with residents and staff. The outcome of which should be submitted to the CSCI. A requirement has been made under Standard 33. Formal staff supervision was not evident in the files evaluated, as stated within Standard 29. On one occasion staff members were observed tilting a wheelchair back when transferring a resident. Footrests were also absent from the chair in use. Such practice is dangerous and places both the resident and staff at an increased risk of accident. The home records all accidents and occurrences within the home. The registered manager was given advice to commence evaluation of the accidents in order to ascertain any patterns and frequency, with a view to taking action to reduce further risk wherever possible. Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 2 X X X X X STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 X 2 X 2 Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP8OP7 Regulation 14 Requirement The registered person must ensure that full assessment procedures are completed, including consultation with appropriate professionals, for those residents who are displaying behaviour associated with dementia or deteriorating mental health. (Timescale of 07/01/05 not met). The registered person must ensure that all staff are trained in managing difficult behaviour associated with dementia and mental health. The registered person must ensure care plans are in place which detail, after assessment, all the residents’ care needs and how they are to be met. (Previous timescale of 15/01/05 not met). The registered person must ensure that risk assessments, and that care plans contain details of how the risks are to be minimised and or managed. Timescale for action 01/04/06 2 OP7 18(1)(c) (i) 01/04/06 3 OP7 15 01/04/06 4 OP7 13(4)(b) 01/04/06 Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 23 5 OP9 13 6 OP9 13 7 OP12 16(2)(m) 8 OP18 13 9 OP22 23 10 OP27 17 11 OP27 18 12 OP29 17 13 OP30 17 The registered person must ensure medication administration records are signed contemporaneously. The registered person must ensure that staff cease handling medication during administration. The registered person must ensure that all residents are consulted regarding their social needs. Ensure residents receive appropriate social stimulation and have the opportunity to join in social activities. The registered person must ensure that all levels of staff complete adult protection training. (Timescale of 15/02/06 not yet elapsed). The registered person must ensure that main lighting in all rooms used by residents is fit for purpose. The registered person must ensure that the staffing rota clearly details staffing positions, duties covered when changes are in place and the actual commencement and completion times. The registered person must ensure that staff are provided in sufficient numbers to meet the needs of residents and increased at peak periods and times of higher demand. The staffing ratio must not fall below that defined within the home’s conditions of registration. The registered manager must ensure that CRB or POVA checks are received before new staff commence their first duty. The registered person must ensure that all staff files contain the required information as detailed within regulations. DS0000063856.V278557.R01.S.doc 22/01/06 22/01/06 01/03/06 01/04/06 01/03/06 01/03/06 01/03/06 22/01/06 11/03/06 Hope Manor Version 5.1 Page 24 14 OP33 26 15 OP33 24 16 OP36 18 The registered person must ensure they complete statutory Regulation 26 visits at the appropriate frequency and produce a report which is submitted to the CSCI. The registered person must compete quality assurance procedures in line with Regulation 24 The registered person must ensure that all care staff receive formal supervision no less than six times per year. 01/03/06 01/06/06 01/03/06 Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 25 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 OP7 Good Practice Recommendations The registered provider should ensure that residents and/ or relatives are consulted regarding the outcome of assessments of needs and the proposed care plan. Signatures of agreement should, as far as possible, be evident. The registered manager should ensure nutritional assessments are in place. The registered person should ensure oral hygiene care is recognised and evident within care plans. The registered person should introduce systems which records residents’ individual participation in activities within their care file. The registered person should have a loop system fitted in parts of the home. The registered person should ensure that armchairs are appropriately cleaned where marks are evident. The registered person should ensure that the duty rota details all the hours worked by staff and the staffing position, including when staff complete cooking and cleaning duties and are in attendance through the on call system. The registered person must ensure that the home’s manager completes NVQ training at level 4 and achieves the Registered Manager’s Award. 2 3 4 5. 6 7 OP7 OP7 OP12 OP22 OP26 OP27 8 OP31 Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hope Manor DS0000063856.V278557.R01.S.doc Version 5.1 Page 27 - 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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