Inspection on 04/06/07 for Knowle Manor

This inspection was carried out on 4th June 2007.

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 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

Knowle Manor 29/06/06

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 Ann Stoner Unannounced Inspection 9:20 4th June 2007 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.V335914.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.V335914.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 Mr Christopher Peters Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. 3. Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is 29. One specific service user in the category of DE, named on the variation dated 21 September 2006, may reside at the home. 29th June 2006 Date of last inspection Brief Description of the Service: Knowle Manor is a local authority home providing personal care without nursing for older people. There are 26 places for permanent occupancy and 3 places for respite occupancy. Accommodation is provided in single rooms, the majority of which have ensuite facilities. The home is on two floors with a passenger lift proving access to the second floor. The 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. There is a car park at the front of the home. The current scales of charges at the home range from £10. 12 per night to £458. 86 per week. More up to date information about fees can be obtained from the home. Copies of previous inspection reports are available in the home. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 5 Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 30th June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by people using the service. More information about the inspection process can be found on our website www.csci.org.uk The visit was unannounced and was carried out by one inspector who was at the home from 9.20 until 17.45. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people living there. Before the inspection evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. A pre-inspection questionnaire (PIQ) had been completed by the home before the visit to provide additional information. Survey forms were sent out before the visit to the people who use the service, relatives, advocates, general practitioners (GPs) and other healthcare professionals. Several were returned, including a letter from a relative of a person living at the home and information provided in this way will be reflected throughout the report. A telephone conversation took place with a relative of a person living at the home before the visit. During the visit a number of documents were looked at and all areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the manager and staff. Feedback at the end of the visit was given to the manager. I would like to thank everyone who contributed to the inspection process and to the home for the hospitality on the day. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 7 What the service does well: The manager sends out satisfaction questionnaires to people living at the home, their relatives and healthcare professionals. He analyses the feedback and produces an action plan to address any issues raised. This information is displayed on a notice board in the home, recorded in the home’s newsletter and discussed at the various meetings held in the home. Comments in returned questionnaires from healthcare and social work professionals included the following statements: • • • • • • • • The staff are very helpful The communication is very good The people living at the home appear happy Knowle Manor is excellent and manages people that other homes don’t, giving people quality of life and choice People thrive in Knowle Manor I have always had a good relationship with management and staff and am always made to feel welcome In the many years I have placed people for respite and permanent care the feedback from families has always been in praise of the standard of care at Knowle Manor. All staff are warm, friendly and are well informed. The home has a private sitting room with tea/coffee making facilities, so that people can have a private conversation with their friends and relatives. This room is nicely furnished. There is also a facility for visitors to stay overnight. One person wrote a letter saying, “I live 5 hours away and travel to Morley once a month. I would like to commend Knowle Manor on having the facility to accommodate me, being able to stay is a great help for me.” There is an excellent information pack in each person’s bedroom giving them details about the service provided at the home, minutes of recent meetings for people living at the home and local places of interest. Comments in survey forms completed by relatives of people living at the home and returned to the CSCI included the following: • • The staff are always willing to help as much as they can The staff can’t do enough; they are always there to offer advice whenever they can. During the inspection people living at the home said: • • • We are informed and consulted about everything I would recommend it to anyone. You are free to do whatever you please, staff don’t interfere. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: The manager showed a firm commitment to addressing the issues raised from this inspection visit. On admission everyone staying at the home should have a contract so that they are aware of the terms and conditions of their stay. Work should continue on developing care plans so that staff have precise information on how to meet people’s needs. This will prevent needs from being overlooked. The format of the care plans should be reviewed so that information can be recorded in detail. The format used for identifying nutritional risk should be reviewed so that it gives an accurate reflection of risk. Infection control measures must be reviewed so that the risk of infection in the home is reduced. The numbers of staff on duty should be reviewed so that the safety and well being of both staff and people living at the home are not compromised. Staff files held at the home should contain copies of two written references and a photograph of the staff member. This will make sure that the home meets the requirements of the Care Homes Regulations 2001. To reduce the risk of errors where money is handed over on behalf of a person living at the home a signature should be obtained from the person handing over the money and from the person receiving the money. Where an accident involving a person living at the home is not witnessed by staff, there should be a record of when the person was last seen and by whom. The format of the accident record should be reviewed so that it is more relevant for people living at the home. Moving and handling training for staff should be updated as required and all care staff should receive training on food hygiene. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 9 A full list of the requirements and recommendations made following this visit can be found at the end of this report. 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. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 10 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.V335914.R01.S.doc Version 5.2 Page 11 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): Standards 1, 2, 3, 4 & 5. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People have enough information to be able to make an informed choice about moving into the home, but they do not have information about the terms and conditions of their stay at the point of admission. EVIDENCE: There is a wide range of information available so that people are aware of the service that the home provides. A notice board near to the entrance of the home has copies of minutes of meetings held for people living at the home, an informative newsletter, and other relevant information. There is a comprehensive information pack in all of the bedrooms that includes information on how to make a complaint, minutes of meetings, a copy of the home’s latest newsletter, an activity programme, local places of interest and a leaflet informing people that snack foods such as soup, beans on toast, cheese and biscuits and cakes along with hot & cold drinks are available on request 24 hours a day. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 12 Care staff said that people thinking about moving into the home are invited to visit. During this visit staff have time to spend with them to discuss their care needs. In a returned survey form one relative said, “We did a lot of homework on different homes which involved visiting numerous homes and speaking to staff, people living at the home and their families. The Knowle Manor team were extremely open and helpful and answered all our questions and worries.” Staff said that they have enough information about people’s care needs before they are admitted. The care records of two people recently admitted to the home showed that an assessment was carried out by a social work professional and the home then carried out its own assessment to make sure that it could meet the person’s needs. The manager said that the licence agreement, which forms part of the home’s contract and terms and conditions, is issued after the person has been in the home for 6 weeks. This means that people do not have accurate and up to date information about the terms and conditions of their stay at the point of admission. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 13 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): Standards 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The health and personal care needs of people living at the home are met. Managers and staff are striving to improve the standard of recording in care records, to reduce the risk of care needs being overlooked. EVIDENCE: It was clear from looking at the care plans of three people that there has been a great detail of improvement in the level of detail recorded, but the format of the plan and the space allowed makes precise recording difficult to achieve. There was a good life history in all of the plans sampled giving a detailed account of the person’s life before admission to the home. Some of the plans were more detailed than others. For example one person’s bathing care plan had excellent information recorded giving details of the person’s preference for a bath rather than a shower, the time she preferred her bath, the type of toiletries she liked, and the level of assistance she needed along with her strengths such as what tasks she could do for herself. But another person’s Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 14 toileting plan did not have important information that was identified in the preadmission assessment about the level of assistance and support required. The pre-admission assessment for this person showed that she was a practising Methodist and went to church every Sunday. Her plan said, ‘If she requests to see a minister, he would visit the home.’ A more pro-active approach is needed to make sure that people’s religious and spiritual needs are met, and the care plan should give staff clear instructions on the action they should take to meet religious and spiritual needs. Moving and handling plans do not specify the precise assistance needed and the precise action staff should take. Nutritional assessments are in place but the nutritional tool in use does not accurately reflect risk. For example one person who is a diabetic controlled by insulin, uses adapted cutlery and needs her food cutting up because of a stroke was shown as being at low risk, which is inaccurate. All people living at the home who returned survey forms said that they always received the medical support they needed. In a returned survey form from a relative one person said, “The family are always invited to be involved in care planning’” and another said, “The home is aware of my mother’s needs and are sympathetic in her care and take into account her age and level of dementia.” A letter received from a relative said, “I live a long way from Morley so having telephone contact with the home is vital for the day-to-day progress of my mother. I phone every few days and I find the staff very pleasant and willing to update me on the day-to-day happenings for my mum.” Evidence in care records showed that people have access to occupational therapists, chiropodists, opticians, district nurses and doctors. From observation and discussion with the manager it was clear that the home manages medication properly. The home uses a blister pack system of administration and this has been extended to include all of the people using the respite service, which is good practice. Staff described the different ways that they protect people’s privacy and dignity. This was confirmed by people living at the home, who said that staff always knock on doors before entering. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People living at the home enjoy a flexible lifestyle where they are able to exercise choice and control over their lives and remain in contact with their family and friends. EVIDENCE: There is a very relaxed atmosphere in the home and people living there can choose what time they go to bed and get up in the morning. During the morning one person was in bed watching television, having a cup of tea and reading the morning newspaper. She said she usually got out of bed just in time for lunch. The manager has introduced a regular newsletter for people living at the home and people confirmed that they are consulted about changes affecting the home during the regular meetings for people living there. An example of this was found in the minutes of one meeting where a discussion had taken place about the value of moving the main meal of the day from lunchtime to teatime. One person confirmed that this issue was discussed and said that the majority of people were in favour of this change and overall it had been a success. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 16 There is a regular programme of activities and on the afternoon of this visit a group of entertainers were visiting. In a returned survey form one person living at the home said, “There are many activities arranged by the home, some of which due to my disabilities I am unable to physically join in, but I am always encouraged to watch and be part of it.” In a returned survey form one relative said, “I wish there were more outside activities but I realise that staff can only do so much with the staffing levels as they are.” This was a view echoed by staff. People living at the home said that ministers of different denominations visit on a regular basis. The home has excellent facilities for people visiting. There is a private sitting room that is decorated to a good standard and is equipped with tea and coffee making facilities. In addition there is a room where relatives can stay overnight if they wish. One relative who lives a considerable distance from the home makes use of this facility when visiting her mother and described it as, ‘a fantastic resource.’ The manager is very good at making sure an advocate is available to support those people who are unable to speak for themselves or make their opinions known. There is a good choice of meals and people described the meals as being, ‘very, very nice with a good choice’, and ‘can’t fault the meals they are excellent.’ The lunchtime meal is a light meal and the main meal of the day is served at 4.30pm. The manager said most people have a late breakfast, so a light meal at lunchtime is more appropriate than a heavy dinner. Tureens and gravy boats are on order to give people more control over their portion size and to increase their independence and self esteem. The menus are nutritious and well balanced. A recent introduction has been ‘Menus of the World’, where a variety of speciality foods from different countries are offered alongside more traditional dishes. In a returned survey form one relative said, “The home is always trying to introduce meals that are a bit different to the norm to give people choice and variety.” This is good practice. Knowle Manor DS0000033246.V335914.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People living at the home and their friends and relatives are assured that any complaint will be dealt with properly. Staff know how to respond to any suspicion or allegation of adult abuse. EVIDENCE: Information about how to make a complaint is displayed throughout the home and there is similar information in each person’s bedroom. All people living at the home who returned survey forms said that they felt that staff listened and acted upon what they had to say. All relatives who returned survey forms said that they knew how to make a complaint. Care workers were able to describe the different types of abuse and knew what to do if they suspected abuse was happening. One person was very knowledgeable about the POVA (Protection of Vulnerable Adults) list. A care officer was clear about how to deal with any suspicion or allegation of adult abuse out of normal office hours. Knowle Manor DS0000033246.V335914.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): Standards 19 & 26. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home meets the needs of the people living at the home but some staff practices increase the risk of cross infection. EVIDENCE: The home is furnished and decorated to a good standard and there are enough toilets and bathrooms to meet the needs of people living there. People are able to personalise their bedrooms and evidence was seen of this during a tour of the building. Some people hold a key to their bedroom door. As a preventative measure following an accident at the home there is now a keypad on a door leading to the first floor staircase. A relative of a person living at the home, said during a telephone conversation before this inspection, “I am always struck by the homeliness of Knowle Manor. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 19 It is nicely decorated and always clean.” All people living at the home who completed survey forms said that the home was always ‘fresh and clean’. Care staff do not routinely wear protective aprons when coming into contact with bodily fluid or clinical waste and domestic staff do not routinely wear gloves and aprons when cleaning toilets. Care staff said they double wrapped used or soiled incontinent pads but supplies of bags were not available in all toilets and bathrooms. Soiled linen is hand sluiced and water-soluble bags are not used for laundering soiled linen. All of this increases the risk of cross infection. The manager agreed to address these issues as a matter of urgency. Knowle Manor DS0000033246.V335914.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): Standards 27, 28, 29 & 30. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Staff are well trained but at times the numbers of staff on duty do not always meet the needs of the people living at the home. EVIDENCE: The recruitment and selection processes are managed centrally and at times this causes difficulties for the home. An example being that the home has had a domestic vacancy for many months, which has put a strain on the existing domestic staff team. The manager said that a successful applicant had been selected but because the full CRB/POVA (Criminal Record Bureau/Protection of Vulnerable Adults) had been requested rather the POVA First check, the process was taking much longer than necessary. This is having an impact on staff morale in the home. Care staff spoke about being rushed especially when there are three care staff on duty. On an evening shift one person administers medication another has to clear away the evening meal because there is no evening kitchen domestic, which leaves one person to carry out caring tasks. There are two staff on night duty. The pre-inspection questionnaire shows that 14 people living at the home suffer from dementia and 3 people need a Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 21 minimum of two staff to undertake their care, which means at times people are left unattended. The recruitment records of a person employed since the last inspection was looked at. There was an application form, but no copies of references, interview records or photograph of the person. The manager said that he had seen the references but they were held centrally. Since the last inspection a number of staff have completed NVQ (National Vocational Qualification) level 2 or above, making a total of 66 of the staff team holding a NVQ certificate. Approximately 50 of staff hold a current first aid certificate. Training during the last 12 months has included first aid, dementia awareness, palliative care, nutrition and care planning. Training planned for the future includes moving and handling, Parkinson’s disease and diabetes; dementia awareness and palliative care training remaining ongoing. New staff complete a thorough induction based on the Skills for Care Common Induction Standards. Knowle Manor DS0000033246.V335914.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): Standards 31, 33, 35 & 38. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home is well managed and the interests and health and safety of people staying at the home are promoted and protected. EVIDENCE: The manager has many years experience in the care of older people and has introduced many changes and improvements in the home. During a telephone conversation with a relative of a person living at the home the manager was described as being ‘lovely’. This person went on to say, “Staff speak to residents lovely”; “The staff can’t do enough”. In a returned survey form an advocate for one person said, “I always find the staff helpful and friendly.” One relative said, “The staff are very receptive to new ideas that are going to benefit the people at the home.” Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 23 Meetings are held with people living at the home, care staff and senior staff. People said that they felt able to speak their minds and were confident that their opinions were valued. The home distributes satisfaction questionnaires to people living at the home, their friends and relatives and healthcare professionals. The manager analyses the responses and then makes these available to everyone. There were some very positive comments about the home on those questionnaires recently returned to the home. Some people hand in money to the home for safekeeping. Records are kept of all transactions but signatures are not always recorded when money is handed over on behalf of a person staying at the home. The manager and the senior staff team carry out regular checks of the money and the system is also subject to regular external audit. All senior managers have completed fire wardens training so they are able to cascade fire training to other staff in the home. The manager has devised a system to identify who needs fire training and when this should take place. He is also in the process of developing a system for recording when mandatory training such as moving and handling has taken place and when updates are due. Moving and handling training is not updated as required and not all care staff have received training in food hygiene. The manager keeps a good analysis of all accidents so that any patterns or trends can be identified. When a person living at the home has an accident that is not witnessed by staff there is not always a record kept of when the person was last seen and by whom. The format of the accident reports are more suited to accidents by staff than they are for people living at the home because there is no space for recording any follow up action and the outcome of the accident. The pre-inspection questionnaire shows that servicing and maintenance of equipment takes place as required. Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 25 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 OP26 Regulation 13 (3) Requirement Infection control measures to prevent the spread of infection in the home must be implemented. This will make sure that the risk of cross infection is reduced. Timescale for action 31/07/07 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 A contract of residency should be available to people at the point of admission. This will make sure that people have accurate and up to date information about the conditions of their stay at the point of admission. Work should continue to make sure that care plans identify all of the person’s needs in every aspect of their life. The format of the plans should be reviewed to make sure there is enough space to record all of detail required. This should prevent needs being overlooked. Moving and handling plans should show the precise Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 26 2. OP7 3 4 OP8 OP27 assistance and support staff should take. The nutritional assessment tool should be reviewed to make sure that it accurately reflects the nutritional risk for each person. The numbers of staff on duty should be reviewed taking in to account the dependency levels of the people living at the home and the layout of the home. This is to make sure that the safety and well being of staff and the people at the home is not compromised. A record of the recruitment interview should be held on staff files. This will provide evidence that good equal opportunities practices are followed. Staff files should include a recent photograph of the person and copies of two written references. This is needed to meet the Care Homes Regulations 2001. The use of POVA First disclosure checks should be considered where appropriate. Where money is handed over on behalf of a person living at the home a signature should be obtained from the person handing over the money and the person receiving the money. This will reduce the risk of errors, misunderstandings and financial abuse. Accident reports should have details of when the person living at the home was last seen and by whom. There should also be a section for any follow up or outcome of the accident. Mandatory training such as moving and handling should be updated as required. All care staff should receive food hygiene training. 5 OP29 6 OP35 7 OP38 8 OP38 Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Knowle Manor DS0000033246.V335914.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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