Inspection on 23/01/08 for Hope Manor

This inspection was carried out on 23rd January 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

Hope Manor 15/01/09

Hope Manor 22/07/06

Hope Manor 22/01/06

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 Adele Berriman Unannounced Inspection 23rd January 2008 10:00 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 Hope Manor DS0000063856.V353588.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. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 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 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 26 older people (OP) requiring personal care only may be accommodated. 22nd July 2006 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. The cost of the service is £395.00 per week. Hope Manor DS0000063856.V353588.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 two star. This means the people who use this service experience good quality outcomes. This site visit was undertaken as part of a key inspection, which looks at all of the key standards. The inspection process also included an analysis of information received by the Commission for Social Care Inspection about the home. An Annual Quality Assurance Assessment was completed by the manager of the service that gave the opportunity for them to record what the home does well, what improvements have been made in the last 12 months and further plans for improvement in the next 12 months. During the visit a selection of records, policies and procedures were assessed. These included records relating to care planning and medication. A tour of some areas of the building took place. Six residents spoke to the inspector and observations were made of the general activity around the home. A number of survey forms were made available to the home for residents, their relatives and staff to give their views about the service. Three relatives of residents living at the home completed a survey. During the visit the atmosphere at the home was relaxed, warm and comfortable. A complaints procedure was available and was also included in the service user guide, which was readily available at the home. Residents said that they would tell the staff if they were not happy with something. The majority of relatives stated that they knew how to make a complaint about the care delivered by the service if they needed to. No complaints had been received by the service since the previous inspection. During the visit to the service staff demonstrated a good awareness of the needs and wishes of the residents. It was evident from the interactions observed that positive relationships had been formed between the residents and staff. Residents spoke positively about the care and support they received from the staff team. These comments included “the staff are very good and caring” and “the staff are very good”. Positive comments were made by relatives about the staff team. These included: “excellent support”, “fully competent in all they do” and “very efficient.” Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 6 All three relatives who completed a survey form stated that they always get enough information about the care home to help make decisions and are always kept up to date with important issues. What the service does well: What has improved since the last inspection? What they could do better: Residents’ assessed needs must be recorded and the manager should develop individual care plans for individuals to ensure that staff are aware at all times of how to meet people’s needs and wishes. Improve the recording system for the ordering, receipt, administration and disposal of medication. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 7 Review and update policies and procedures in place to safeguard residents. Ensure that these policies and procedure fully consider the needs of the people who live at Hope Manor. Ensure that fire doors are only wedged open by devices that would automatically release in the event of a fire. Ensure that all staff files demonstrate that appropriate checks have been carried out prior to them commencing employment. 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. Hope Manor DS0000063856.V353588.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 Hope Manor DS0000063856.V353588.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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ care needs were assessed by the home; however, failure to record this information in full may result in people not receiving the care and support they need. EVIDENCE: A representative of the service visits prospective residents prior to them moving into the home. The purpose of the visit is to carry out a needs assessment to ensure that Hope Manor has the facilities to meet the needs of the individual. People’s needs were recorded on a dependency chart proforma. This was in the form of a tick-box chart that covered all aspects of people’s day to day life. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 10 Copies of these charts were present on some of the care files assessed. However, some had little or no information written on them. It is essential that detailed records of people’s needs and wishes are maintained at all times. Failure to do so may result in a person’s needs not being met. All three relatives who completed a survey form stated that they always had enough information about the home to make decisions. One relative wrote “they keep us well informed of their needs and generally do all things required of them quite well.” Hope Manor does not provide intermediate care facilities. Hope Manor DS0000063856.V353588.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ health and personal care needs were being met by the home. However, the lack of written information about people’s assessed care needs could result in a person not receiving the care and support they require. EVIDENCE: Each resident had their own individual file that contained their care plan. Six files were assessed during the visit. The files contained personal details of the individual, GP, hospital and medical information. A needs assessment formed part of the residents’ care plans. The format of this assessment contained all aspects of the individual day-to-day needs. Copies of these assessment charts were present of all residents’ files. However, some had little or no information written on them. There was little evidence of individual risk assessments for known risks to individuals. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 12 Some files demonstrated people’s dependency needs by a scoring between one to five but there was no information available to say how and when a person’s needs were to be met. There was little opportunity to record a person’s cultural, social, or recreational needs and there was no evidence that the Mental Capacity Act (2005) had been considered in care planning. It is essential that residents’ needs and wishes relating to all aspects of their lives are recorded in full. Failure to do so may result in a person’s needs not being met. Care plans contained the opportunity for staff to record when a care plan had been reviewed. However, the last recorded dates for reviews of care plans were May 2007. It is essential that people’s care plans are reviewed and updated on a regular basis. Failure to do so may result in a person’s needs not being met. The manager stated that they were awaiting the delivery of a new care planning format as the previous format was not appropriate. Staff stated that whilst they were awaiting the new care planning documents, they were recording all information relating to residents in their daily records. A selection of these records were assessed. Several demonstrated that people’s health care needs were being addressed by their GP, district nurse visits, etc., and contained clear information about the individual. Some records contained only minimal information, for example, ‘xxxx good day ate drank.” It is essential that detailed information is recorded about what residents had experienced during their day. Failure to do so may result in a person’s needs and wishes not being met. Some policies were in place regarding the administration of medication and senior members of staff on duty, responsible for the administration of medication demonstrated a good knowledge of individual residents’ medication. The cabinet in use for the storage of controlled drugs was not compliant with recent changes in legislation to the storage of medication. The majority of medication was dispensed from the pharmacy in monitored dosage systems. Staff recorded on a Medication Administration Record (MAR) when they had administered medication. Excessive stocks of some medication were being stored. There was little evidence on the MAR sheets that stock carried forward from the previous month’s prescription was being counted and therefore no clear audit trail of the management of medication was available. It is essential that records demonstrate what medication has been ordered, delivered, administered and returned to the pharmacy to demonstrate that residents are receiving their prescribed medication. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 13 Information written on Medication Administration Records was contradictory. It is essential that all records are checked on a regular basis to ensure that they contain the correct information. Failure to do so may result in residents not receiving their medication at the time that it was prescribed. Throughout the visit staff were seen to support residents in a manner that maintained their dignity. Hope Manor DS0000063856.V353588.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents benefit from a well balanced and varied menu. Changes to the way residents occupy their free time need to be made to improve their experiences in the home. EVIDENCE: During a discussion with five residents they confirmed that could receive visitors at any time. Residents said that they had a person who visited on a weekly basis to do keep fit, have a quiz and a sing-song. Sing-songs also take place through the week. An outside entertainer also visits occasionally. One resident commented that there was not much else to do, other than watch television. Two relatives also commented about the activities available at the home. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 15 One person stated ‘I think the care home should organise more activities. There is a lady that comes in once a week to do a quiz and exercise, this is not enough. They need more stimulation, a lot get no visitors, so never have a conversation’. The other person stated ‘they could provide more entertainment. They rely a lot on the TV.’ During the visit one resident was observed being supported and encouraged to play the piano in the lounge. The service invites churches to visit the home to support residents to keep and practice their faith. Residents stated that they had a choice of when they got up and went to bed. A four weekly menu was available that demonstrated a balanced diet was offered. The main cooked meal of the day was served at lunchtime, except on a Thursday when it is served at tea time so that residents do not have a heavy meal prior to armchair exercise sessions taking place. During the visit residents spoke positively about the meal they had had for tea. One man had requested a sandwich for his supper that evening and staff were seen offering residents a choice of snacks at suppertime. Staff stated that individuals dietary needs were catered for, for example, some foods were made specifically for people with diabetes. Hope Manor DS0000063856.V353588.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People were confident in the home’s complaints procedure. Attention to policies and procedures in the home would benefit staff in caring for residents. EVIDENCE: The home had a complaints procedure that was included in the service user guide which was readily available at the home. Residents said that they would tell the staff if they were not happy with something. The majority of relatives stated that they knew how to make a complaint about the care delivered by the service if they needed to. A copy of Salford Social Services’ Adult Protection Procedures was readily available to staff. The home had its own policy on adult abuse. The information in the policy was outdated and did not refer to or reflect Salford Social Services’ joint agency policy. It is essential that an accurate policy/ procedure is available for staff to refer to in the event of a concern being raised. Failure to carry out the appropriate procedures may result in a situation not being managed appropriately. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 17 A ‘Management of Violence Policy’ was available for staff. The policy detailed the ‘the agreed procedure for the care of violent residents’ and stated the procedures staff were to follow in the event of physical restraint being needed in a situation. There was no evidence in residents’ care plans of restraint being part of their care, nor was there any evidence of staff having the appropriate training for this type of behaviour management. It is essential that all policies and procedures in operation contain information relevant to the service delivered at the home. Hope Manor DS0000063856.V353588.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home is generally well maintained, providing a comfortable environment for people to live in. EVIDENCE: A handy person is employed at the service as and when needed. At the time of the visit the downstairs hallways were in the process of being decorated. Several bedrooms had recently been decorated as part of the home’s ongoing refurbishment. The home had recently replaced all the carpets throughout the home and had new chairs in the communal lounges; residents said that these chairs were very comfortable. Several bedrooms were visited during the inspection. All were found to be pleasantly furnished and contained residents’ personal effects. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 19 Some toilet doors were signed to identify the room. However, bedroom doors did not contain any number or name. It is recommended that all doors around the building are signed. This would help residents with their orientation around the home. The home was warm, clean and tidy. One relative wrote “always kept fresh and clean.” One bathroom on the first floor was being used as a storage room. It is strongly recommended that items are removed from this room to ensure that the facility can be used by people. There was no fire risk assessment available. The manager stated that a contractor was visiting Hope Manor on 4th February 2008 to carry out this assessment. Throughout the visit several doors, including designated fire doors, were wedged open. It is essential that appropriate actions and equipment are used at all times. Failure to do so may result in people being put at unnecessary risk of harm. Hope Manor DS0000063856.V353588.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents were supported by a team of staff who know their needs and wishes. EVIDENCE: There were three care staff on duty at the time of the visit and the deputy manager was carrying out the role of cook. The staff rota demonstrated that three staff and the manager were on duty for that morning. It is recommended that the rota demonstrates when the manager is available to carry out their managerial responsibilities. During the visit to the service, staff demonstrated a good awareness of the needs and wishes of the residents. It was evident from the interactions observed that positive relationships had been formed between the residents and staff. Residents spoke positively about the care and support they received from the staff team. These comments included “the staff are very good and caring and “the staff are very good.” Positive comments were made by relatives about the staff team, including: “excellent support”, “fully competent in all they do” and “very efficient.” Relatives commented that staff always have the right skills to look after people and meet the different needs of people. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 21 Five staff files were assessed during the visit. Two files contained all the information required. Other files did not contain all the information required to demonstrate that appropriate checks had been made on people’s references or proof of identification. It is essential that all of the documents listed in schedule 2 of the Care Homes Regulations 2001 are maintained on a member of staff’s file to demonstrate that appropriate recruitment procedures have been followed. The manager stated that newly recruited staff receive a verbal induction into their role and that an experienced member of staff is made available as a mentor. It is strongly recommended that staff’s induction process is recorded and placed on the staff member’s file. There was evidence on some staff files of a skills and training matrix that demonstrated what training staff had undertaken, this included equal opportunities and diversity, foundation certificate in health and safety in the workplace, appointed person first aid, basic food hygiene, safe medication handling and dementia awareness. The manager stated that most training was accessed through the Salford Training Partnership. Over 50 of the staff team had achieved an award NVQ level 2 or above. The deputy manager had recently completed their NVQ level 4. Hope Manor DS0000063856.V353588.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): Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Policies and procedures in place minimised the risk of harm to people’s health, safety and wellbeing. EVIDENCE: The manager of the service holds the NVQ level 4 and the registered manager’s award. During the visit she demonstrated a detailed knowledge of the residents’ needs and wishes, along with a commitment to continually improving the services offered at Hope Manor. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 23 There was no written policy for the management and storage of residents’ personal finances. However, a system was in place in which people’s personal property was stored securely. An account book was available that detailed money transactions of the residents. It is recommended that the account book is signed by staff when they record an entry in the account book. Three balances of residents’ monies held were checked and were correct. A health and safety policy was available, along with an employee safety handbook. Risk assessments were also available to minimise the risks to people’s health, safety and wellbeing. It is recommended that these documents are reviewed on a regular basis to ensure that they always contain current, up to date information. Information supplied by the manager demonstrated that servicing and testing of electrical equipment, the lift, fire detection equipment, heating systems and gas appliances had taken place. Hope Manor DS0000063856.V353588.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 14/03/08 2 OP9 13 3 OP19 23(4) Detailed information must be documented and available at all times in care plans that demonstrates what individuals’ needs and wishes are, any identified risks and what actions are required to meet these needs and wishes. Care plans need to be reviewed on a regular basis to ensure that people delivering care and support have up to date information on how a person’s needs are to be met. Medicines must be recorded as 14/03/08 being given to residents as prescribed. Receiving medicines at the wrong time may seriously affect the health and wellbeing of residents. 14/03/08 To ensure the safety of all, the practice of wedging designated fire doors must cease and, if required, appropriate automatic door closures put in place. A detailed up to date fire risk assessment must be in place at the home at all times. All staff files must contain the DS0000063856.V353588.R01.S.doc 4 OP29 19 14/03/08 Page 26 Hope Manor Version 5.2 information listed in Schedule 2 of the Care Homes Regulations to demonstrate that appropriate recruitment checks have been completed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP3 OP7 OP9 OP12 Good Practice Recommendations Detailed records of residents’ assessed needs should be maintained at all times, to ensure that staff supporting the residents are fully aware of what their needs are. Daily records need should contain detailed information about the experiences of the residents that day. A legally compliant controlled drugs cupboard should be available to store controlled drugs so they are not mishandled or misused. A review of activities available at the home should take place and include people’s preferences, relating to their social, recreational and cultural needs and wishes to ensure that people receive stimulation on a regular basis. This information should be considered and recorded when developing a resident’s plan of care. The adult protection procedure should be reviewed and updated to include up to date procedures in the local area and refer directly to Salford Social Services’ Safeguarding procedures. The policy on the management of violence should be reviewed and updated to reflect and contain information appropriate to the service delivered at the home. This is to ensure that people who challenge the service are supported appropriately. Staff should have instant access to an ‘override’ key to all bedrooms for use in the event of an emergency. All items being stored in the upstairs bathroom should be moved to allow full access to the facility. Signs should be placed on doors to identify the room. This would assist residents with their orientation around the DS0000063856.V353588.R01.S.doc Version 5.2 Page 27 5 OP18 6 7 8 OP19 OP19 OP19 Hope Manor 9 10 11 12 OP27 OP30 OP35 OP38 building. The staff rota should demonstrate the times that the manager is carrying out administration and other activities attached to the manager’s role. The service should develop a formal induction process for new staff and record in detail what has been included as part of the person’s induction into their role. A written policy for the management of residents’ monies within the home should be devised and implemented. A regular review of policies and procedures relating to people’s health, safety and wellbeing is recommended to ensure that they always contain the most up to date information. Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Hope Manor DS0000063856.V353588.R01.S.doc Version 5.2 Page 29 - 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!