Inspection on 29/06/06 for Knowle Manor

This inspection was carried out on 29th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Knowle Manor 04/06/07

Knowle Manor 28/11/05

Knowle Manor 05/10/04

Knowle Manor 29/04/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Knowle Manor Tennyson Terrace Morley Leeds LS27 8QP Lead Inspector Dawn Navesey Key Unannounced Inspection 29th June 2006 09:40 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 Knowle Manor DS0000033246.V300835.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. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Knowle Manor Address Tennyson Terrace Morley Leeds LS27 8QP 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) 0113 2534740 0113 2538728 Leeds City Council Department of Social Services Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 Brief Description of the Service: Knowle Manor is a local authority home providing personal care for 26 permanent residents and 3 respite places for people over pension age. Accommodation is provided in single rooms, the majority of which have ensuite facilities. The home is on two floors and has a passenger lift. The generous communal areas are on the ground floor where there is a large dining room and a choice of lounges, one of which is a designated smoking area. The home is situated close to Morley town centre where there are a wide range of amenities including shops, library, doctors and dentists. The home is well served by public transport with bus services running to and from Leeds and other local areas. The current scales of charges at the home are from £70.85 to £458.86 per week. Respite is charged at £10.12 per night. Additional charges are made for hairdressing, toiletries, newspapers, periodicals and podiatry. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced inspection was carried out by one inspector between 9-40am and 5pm. The purpose of this inspection was to monitor progress in meeting the requirements and recommendations made at the last inspection, and to make sure the home was providing a good standard of care for the people living there. The people who live at the home prefer the term resident; therefore this will be used throughout the report. The methods used at this inspection included looking at care records, observing working practices and talking to residents, visitors and staff. Information gained from a pre-inspection questionnaire and the home’s service history records were also used. Comment cards were left at the home to provide service users and visitors with the opportunity to comment on the service. Feedback was given to the manager and one of the officers at the end of the inspection. Requirements and recommendations made during the visit, and outstanding from previous visits can be found at the end of this report. What the service does well: Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 6 The home has a relaxed and friendly atmosphere. Staff and residents have a great rapport. One resident said, “ Staff are very kind and there’s always enough of them.” The standard of décor and furnishings is good and the home is very clean. There is a good range of activities on offer. Something is organised every day. Trips out of the home are arranged and 1-1 activities take place with residents and their key workers. Residents said they enjoyed the food at the home and there is plenty of choice. A number of residents said they enjoyed having such choice and could have “anything you want.” Residents and relatives are encouraged to share their views and be involved in the day to day running of the home, through being involved in meetings or completing questionnaires. There is good teamwork within the staff team. All staff are included in meetings and training events to make sure there is good communication. Staff work flexibly to meet the needs of the residents and the service. What has improved since the last inspection? Although there is still some work to be done, the new manager and the staff team have worked hard to improve the care records. Some residents’ care plans now have a good level of detail about care and support needs. The outside of the home has been painted and attractively decorated with stencils. The garden areas have been well maintained with new garden furniture and potted plants. An administrative assistant has now been recruited. The new manager has been recruited and is now in post. Comments from residents and staff showed they were happy with the new manager and he has had a positive impact on the home. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 7 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. Knowle Manor DS0000033246.V300835.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 Knowle Manor DS0000033246.V300835.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have reasonably sufficient information available to make an informed choice about the home. Pre-admission assessments are led by the social workers or care managers rather than the home manager. EVIDENCE: The statement of purpose has been updated to include information about the new manager. All residents are shown the statement of purpose and service user guide prior to moving in to the home. A copy can be kept if they wish. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 10 Pre-admission assessments are mainly carried out by the social workers who refer residents. The manager said he would follow up any gaps in information prior to residents moving in. The manager should consider the use of a preadmission assessment document to make sure the home could meet prospective residents’ needs. Prospective residents can visit the home prior to moving in or coming for respite care. One resident said, “ I came to visit and thought it was lovely, clean and everyone was so friendly.” Staff talked about the importance of helping people to settle in and that allocating key workers who have similar interests to residents helps this process. An emergency admission had taken place the night before this visit. The manager was trying to gain as much information as possible so that the home could meet this person’s needs. This is good practice. A number of residents have recently had their needs reviewed. Where it was found the home could no longer meet the person’s needs a more suitable placement was arranged. Some residents did not have written terms and conditions on file. This means that residents do not have information on how much the service costs them. Knowle Manor DS0000033246.V300835.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although progress has been made in improving the care records, the variable level of detail means that some health and personal care needs could be overlooked. Residents are protected by safe systems for dealing with medication. Residents’ privacy and dignity is respected. EVIDENCE: Residents’ care plans, which are known as Lifestyle Plans showed further signs of improvement. The new home manager has chosen this area as his priority and has audited all residents’ plans and risk assessments. From this audit, he Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 12 has given staff training on care planning using a person centred approach. Staff said they had really enjoyed the training and felt more confident in this side of their work. One staff member said she enjoyed doing the care plan work, involving residents and getting to know them better. A number of staff were seen to be working on the care plans with residents during the visit. The manager has developed an action plan for every resident in terms of what key workers need to do to improve the care plans and risk assessments. Some of the completed assessments and care plans had detailed, person centred information on residents’ needs and how they were to be met. They gave information on residents’ likes, dislikes and preferences. There is also some excellent information in the residents’ pen pictures giving the reader a real sense of who the person is and their life history. Work must continue to make sure all residents have detailed plans showing how their needs will be met. The format of the Lifestyle Plans does not give a lot of space to write a detailed plan of care. Some consideration should be given to making changes to this document. Risk assessments have been carried out for some identified risks to residents, however more detail is needed. Nutritional assessments need to be updated for those at risk from weight loss. Those at risk from falls and pressure sores need detailed risk assessments and action plans written. There were some inappropriate entries made in resident’s daily notes. Terms such as “demanding” and “nattery” do not accurately describe resident’s behaviour. The manager was aware of these entries and was addressing report writing in the training he is currently doing with staff. Health care needs of residents are attended to promptly. Records of all contact with health professionals are documented in residents’ files. One resident said, “they will get a doctor for you anytime you need one.” A questionnaire had been completed by a visiting health professional. Comments included “Residents receive whatever is best for them, staff try to achieve this at all times.” The home uses a monitored dosage, pre-packed system for medication. All senior staff have received training on how to use the system. Photographs had been taken of all residents, which made sure they are clearly identified on medication records. The manager is planning to obtain photographs of residents who come for respite care too. Good practice was seen during the visit on the administration of medicines. Residents were given their medication individually and supervised as necessary. The manager has completed accredited medication training. It would be good practice to extend this to this to other staff who are responsible for medication administration. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 13 Staff had an excellent rapport with residents. They were seen to be patient, kind and friendly. Staff spoken to said they liked to give residents as much independence and choice as possible in order to keep them active and maintain their dignity. Staff supported people and offered assistance with courtesy and respect, always asking people if they needed help before giving it. A resident said, “Staff are lovely here, very good, always get what you need day or night.” A visiting relative said she was happy with the care provided. Knowle Manor DS0000033246.V300835.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provided within the home and community take into account the preferences and interests of the residents. Residents have a well- balanced and nutritious diet, with their choices catered for as much as possible. The home encourages contact with relatives and friends. EVIDENCE: The home has an activity plan showing varied and regular activity. There is something on offer each day. Activities include arts and crafts, board games, quizzes, gardening, reflexology, hand manicures, massage and activities in the community such as shopping and trips to local parks and garden centres. The manager reviews the enjoyment of activities at residents’ meetings and Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 15 through the use of questionnaires. Changes if needed, are then made to the activity plan. The residents and staff are currently working on a gardening project. One of the residents is particularly involved in this, using his past experience and interest in gardening to the full. He is hoping to win the first prize this year in a Leeds City Council competition. Residents said they enjoyed 1-1 activity with their key workers, such as going out shopping in Leeds or more locally in Morley. A resident who was at the home for respite care said she was pleased she had been out on a trip to a local garden centre and café. Relatives said they are always made welcome and informed of anything that affects their relative. The home has facilities for residents to meet with their friends or relatives in private. There is also a room where relatives can stay overnight if they wish. During the visit residents were occupying themselves by reading newspapers, watching TV, knitting, gardening or chatting with other residents and staff. The reflexologist also visited in the afternoon. The home manager is planning to use some recently donated money to buy a DVD player to be able to offer films as a choice of activity. There are also plans to buy a karaoke machine to enhance the sing- a- long activities. A Catholic priest visits the home to give communion to Catholic residents. A Church of England vicar also visits the home for residents of that denomination. Menus are varied and nutritionally balanced. Menus are developed after consultation with residents at a meeting or on an individual basis. The new manager and the cook are consulting with residents and hoping to develop a summer menu offering food choices more suitable to warmer weather. Meals are served in the dining room or residents may have their meals in their own room, in one of the lounges or outside on the patio in the warmer weather. The dining room tables are arranged in small group settings that encourages conversation and makes meal times a social occasion. Residents are offered a choice of meals at every mealtime. Choices are made through staff asking residents what they want each day. All residents spoken to said they enjoyed the food. One resident said, “There are plenty of choices, anything you want you can have. We have every pudding you could imagine.” The lunchtime meal was cottage pie or turkey drummers served with roast potatoes, cabbage and carrots. This was attractively presented. There was a choice of four puddings, which also included fresh fruit. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 16 Any resident who needed assistance at meal times was given this discreetly and with courtesy. Drinks were on offer at regular intervals. Jugs of juice and water were available in each of the lounges. Staff regularly assisted those who were not able to help themselves. Residents who are able to look after their own money are encouraged to do so. One resident said it was important that she kept her own purse on her saying “You never know when you might need something.” Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 17 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives concerns are listened to and acted upon. Residents are protected from abuse. EVIDENCE: A complaints procedure is available to all residents and is part of the service user guide. A visiting friend of a resident said she was aware of how to complain if needed and also added that she would complain to the CSCI (Commission for Social Care Inspection) if she felt this was necessary. A number of residents said they had never had to complain but would go to the manager if they needed to. During the visit a resident mis-placed her purse. She received a prompt response to reporting this and the purse was found within minutes. The manager has dealt with any complaints the home has received properly and sensitively. There is an on-going complaint from a neighbour about noise Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 18 from the kitchen’s extractor fan. The manager has agreed on action to minimise this. The manager is aware of his responsibility to report any serious complaints to the CSCI. Staff were familiar with the adult protection procedures and have received training on abuse and the protection of vulnerable adults. Staff were aware of the different types of abuse and how to report any concerns. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a clean, safe, pleasant well-maintained environment both inside and outside the home. EVIDENCE: The home was very clean, tidy and attractively furnished and decorated. Residents commented on how hard staff work to maintain this standard. It is light and airy and well laid out. The manager is currently looking at discreet ways of providing direction signs to assist residents who may forget their way round the building. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 20 Residents’ bedrooms are attractively decorated and individual to the person. Residents are encouraged to bring in their own familiar pieces of furniture, ornaments and pictures. Most rooms have en-suite toilets. The rooms for residents on respite care are pleasant and homely. Residents on respite care are encouraged to bring photographs of family and friends in for their stay. The manager is currently reviewing the vinyl floor covering in these rooms to be assured it is non-slip. There are a number of small lounge areas offering residents a choice of where to sit. One of the lounges has been designated as a smoking lounge another is a quieter lounge for residents to read or sit quietly if they wish. There are plenty of toilets and bathrooms for residents. These are all very clean and well equipped. The kitchen was clean and hygienic. The cook takes responsibility for kitchen cleaning tasks and recording of food and fridge temperatures. All staff wore protective clothing before entering the kitchen. Infection control is well managed. Staff have received training and were seen to wear protective aprons and gloves when assisting residents to the toilet. The home has some attractive garden areas. These are mainly patio style with plenty of potted plants, garden decorations and seating. The residents and staff are currently working on the development of a sensory garden in one of the patio areas. The outside of the building has been newly painted. The manager conducts a monthly health and safety check of the building and premises. Any hazards or maintenance issues identified are logged and then reported for action to be taken Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff meet residents’ needs. Residents are protected by the home’s recruitment procedures. In the main, staff are trained and competent to do their job. EVIDENCE: Rotas are well planned with enough staff on duty to meet residents’ needs. There are usually between three and four care assistants on the morning shift and three on the afternoon shift. In addition to this, there is the manager, a care officer or a senior care officer on duty every day. The home also has domestic, catering and laundry staff on duty daily. Two care staff are on duty at night with on call back up if needed. All staff spoken to said they feel there is enough staff on duty and time to meet residents’ needs. Some staff said it would be nice to be able to get out Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 22 on individual activities more with residents if they had more staff. All residents spoken to said there were enough staff on duty, day and night. The home has now filled the vacant administrative assistants post. The candidate is awaiting all the recruitment checks and will soon be in post. The number of care staff who have achieved their NVQ (National Vocational Qualification) level 2 or above has increased to 38 . There are a further four staff who are now undertaking this qualification. Records relating to recruitment are held centrally at the organisation’s head office. A checklist is kept at the front of the staff’s file noting that recruitment records, references and CRB (Criminal Record Bureau) checks have been done. Staff complete induction training when they start their employment. Training such as moving and handling, principles of care, fire awareness and first aid are completed first. Some staff now need updates in some of this training. Staff’s training records are documented on the home’s training plan and transferred annually in to their individual files. Fire training however, is not documented on the plan but in the fire log book. This could lead to some staff missing their updates. The manager agreed to transfer this information on to the training plan. Staff were very pleased with recent training events in the home, such as the sessions on care planning, saying they felt their confidence and skills were now much improved. Staff had also recently attended dementia awareness training, which they said made them feel better equipped to care for anyone with dementia or to recognise the signs of it. Catering and domestic staff have also done this training to make sure there is a consistent approach from all staff. Night staff work flexibly to enable them to attend training sessions. Staff had a good understanding of their role, especially their key worker responsibility and felt well supported by the management team. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 23 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): 31,33,35,36 and 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home is well managed; the interests of the residents are seen as important to the manager and staff. Staff are properly supervised. Residents’ financial interests are safeguarded. Health, safety and welfare are promoted. EVIDENCE: Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 24 Residents and relatives said how pleased they were with the home’s new manager. They said they find him approachable and think he will be very effective in the home. One visitor said that her relative had said, “ I love the new manager, he is organised and will sort things out.” The manager is currently in the process of applying to CSCI to become the registered manager of the home. He has been very prompt with this application. He has almost completed his NVQ level 4 in management. Staff spoke positively about the management team. All staff spoken to confirmed that they have regular supervision and really enjoy this time. They said it is useful and effective, giving the example of coaching in writing care plans. The manager works flexibly to enable him to give night staff supervision. Staff said they felt the new manager would now give some stability to the home as they had experienced a few changes in management, which they had found unsettling. The manager has shown good leadership skills by assessing what needs to improve at the home, prioritising this and working alongside staff to make sure it gets done. There is a Quality Assurance questionnaire in place, which asks for comments from residents, relatives and professional visitors to the home. The manager has analysed this information and produced action plans to make sure of improvements in the service. Monthly visits are carried out by the organisations Principal Unit Manager. Financial procedures in the home make sure that each resident’s money is kept separately. Residents have access to their money at all times. The manager completes a weekly check of all financial transactions. Property handed over for safekeeping is recorded properly. Staff meetings take place monthly. Night staff are invited to attend the meetings. However, if they can’t the manager holds a meeting with them to make sure communication is kept up. Accident reports are completed for any accidents or incidents. These are analysed on a monthly basis to identify any patterns or trends. It would be good practice for the accident form to have space to write when residents were last seen and by whom and a space for any follow up or outcome of the accident. Health and safety is well managed. A monthly audit is completed, fire records are well maintained and environmental risk assessments are in place. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 25 The manager is aware that the organisation’s policies are reviewed centrally but said that any local guidelines needed to enhance the policies would be introduced at Knowle Manor, if needed. Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 Requirement All residents must have an up to date contract with their current fee levels detailed. The service users plans and risk assessments must set out in detail the actions that need to be taken to ensure all aspects of health, personal and social care needs are met. Previous timescales of 31/03/05, 14/09/05 and 31/03/06 have not been met in full. 3. OP28 19 Progress must be maintained to achieve the target of having 50 of care staff qualified to NVQ level 2 or equivalent. The previous time scale of 31/12/05 has not been met. 1. OP30 19 Staff’s training such as first aid and moving and handling must be kept up to date. 30/09/06 30/09/06 Timescale for action 30/09/06 2. OP7 15 31/08/06 Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 28 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 OP3 Good Practice Recommendations Some consideration should be given to the home having its own format for pre-admission assessments to make sure care needs are not overlooked. The format of the Lifestyle Plans should be reviewed to see if more space can be given to write detailed plans of care. All staff should receive accredited medication training. Accident reports should have details of when residents were last seen and by whom. There should also be a section for any follow up or outcome of the accident. 2. 3. 4. OP7 OP8 OP38 Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Knowle Manor DS0000033246.V300835.R01.S.doc Version 5.2 Page 30 - 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. 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