Inspection on 31/10/05 for Madeley Manor Care Home

This inspection was carried out on 31st October 2005.

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

Madeley Manor Care Home 01/11/07

Madeley Manor Care Home 26/07/06

Madeley Manor Care Home 06/04/05

Madeley Manor Care Home 28/09/04

Madeley Manor Care Home 28/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Madeley Manor Care Home Heighley Castle Way Madeley Crewe Cheshire CW3 9HJ Lead Inspector Lynne Gammon Announced Inspection 31st October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 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. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Madeley Manor Care Home Address Heighley Castle Way Madeley Crewe Cheshire CW3 9HJ 01782 750610 01782 751545 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) Madeley Manor Care Home Limited Julie McCormack Care Home 42 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (42), Physical disability (5), Physical disability over 65 years of age (42) Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical disability minimum 55 years - 5 beds Date of last inspection 6th April 2005 Brief Description of the Service: Madeley Manor Care Home provides residential and nursing care for up to 42 elderly persons over the age of 65 years, physical disabilities elderly and older people, (42 beds) mental disability (5 beds), (excluding learning disability or dementia), dementia (5 beds) and physical disability minimum 55 years of age, (5 beds). The Home is a Grade II listed country house situated in landscaped gardens on the outskirts of Madeley in a well established residential area. The Home is approximately 5 minutes from Madeley village, 6 miles from Newcastle-under-Lyme and 8 miles from junction 15 of the M6 motorway. The Home is not well served by local transport but is easily accessible by car and has parking space to the front of the home. Accommodation within the Home is provided on three floors that are accessed by a vertical shaft passenger lift or a main staircase. All areas within the Home are accessible for wheelchairs. There are 32 single rooms and 4 double rooms, most of which have en-suite facilities. Madeley Manor has two well appointed sitting rooms overlooking the extensive grounds and a good sized dining room. There is access to the grounds and a newly laid patio area has been provided for the benefit of the service users. The Home provides a range of activities for service users and has access to a community minibus to provide day trips for those living in the Home. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced visit was made on the 31st October 2005 at 9.30 a.m. The inspection was carried out by two inspectors who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 8 hours. On the day of the inspection, there were 38 service users. The registered care manager, Julie McCormack and the general manager, Diane Maddock was present throughout the inspection. The inspection included a tour of the home, inspection of records, observation and discussions with service users, relatives and staff. Since the last inspection on 6th April 2005, no formal complaints or any incidents or reports of abuse of any kind had been received by the Commission for Social Care Inspection or the home, and no requirements or recommendations, against the regulations or the minimum standards, were outstanding from the last inspection report. The statement of purpose and service user’s guide provided sufficient information to enable service users and their families to decide if the home was right for them, being sure that it could meet their needs and once in the home, having those needs met very well. Changes had taken place in terms of staffing numbers and slight amendments to the statement of purpose were required to reflect this. All aspects of social, health and personal needs were addressed to a very good standard and recorded accordingly. Service users spoke highly of the quality of care provided by the staff within the home and confirmed that they had access to a range of other health care professionals. Both externally and internally, the home was well maintained and fit for purpose. It provided a safe and homely environment for the service users and was very clean, warm and tidy. One of the main communal areas and a number of bedrooms had recently been redecorated to a high standard and the dimensions and layout of the rooms were adequate to meet the needs of the service users. The home was generally well managed and the service users and staff were supported to have their say and to influence decisions about the day-to-day running of the home. Recruitment and selection procedures were robust for all permanent staff and further vetting was required for agency staff. Staff training did take place but needed to be better organised to clearly identify historic training and future training needs. Financial recording was accurate Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 6 but receipts should be provided for each financial transaction to ensure the ongoing protection of service user’s monies. What the service does well: What has improved since the last inspection? What they could do better: No requirements were raised as a result of this inspection. Six recommendations were made as follows: • • the Statement of Purpose to be updated to accurately reflect current staff numbers care plans to include identified risks and associated risk assessments which are easily recognised by staff to ensure that all aspects of health and safety are maintained at all times Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 7 • • • • the signature list of members of staff authorised to administer medication to be updated to include the changes to staff that have recently taken place to review the vetting procedures for agency staff to develop a training matrix to provide a clear tracking process of training that has taken place and to include any proposed dates for future training. Also training to be provided for all staff on infection control, dementia and abuse awareness. a receipt to be given for every financial transaction taking place within the home, and when responsibility for valuables and possessions is transferred from service user to the Home and vice versa. 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. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 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 Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 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, 3 & 5 Service users received detailed information about the home and the service it provided to enable them to make an informed choice. The home had clear assessments of the service user’s individual needs, which enabled staff to support them appropriately. Trial visits were available for all prospective service users and their families to enable them to assess the suitability of the home. EVIDENCE: The statement of purpose and service user’s guide were in place. These documents were well presented and contained all the relevant information required. The matron said that all new service users received copies and that copies were also available in the reception area. The documentation was clear and comprehensive and outlined the Madeley Manor’s philosophy of care. It was noted that information relating to staff numbers was no longer correct. This was discussed with the manager and general manager at the time of the inspection who said that they would ensure that this section was amended. A random sample of four service user’s care files was inspected. Care management assessments were found to be in place and areas of need Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 10 highlighted within the assessments were also present within the plans of care drawn up within the home. Five service users who were spoken with all confirmed that they had visited the home and stayed on a trial basis, before they made a decision to stay. The matron confirmed that this was standard practice within the home. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 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 11. Care planning processes within the home were detailed and consistent to provide staff with sufficient information to meet service user’s needs satisfactorily. All health care needs were met and there was a safe system in place for the receipt, storage and administration of medicines for the protection of service users. EVIDENCE: Four service user’s care plans were studied in depth and were detailed and thorough and covered the assessed needs of the service users. This included admission details, aspects of care, daily report, professional’s visits and risk assessments. A night time assessment had also been completed for each service user. Care plans were reviewed monthly and the standard of recording was very good and meaningful, particularly in regard to nursing care such as the wound progress sheet. Care plans included signatures of relatives who had been involved in the development of the plan. Risk assessments were seen to be in place for smoking, use of bed rails (including consent forms also signed by relatives) and a number of other key areas including falls. These were reviewed regularly, however, a discussion took place regarding the need to ensure that identified risks and associated Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 12 risk assessments were easily recognised by staff to ensure that all aspects of health and safety are maintained. From inspection of records and discussion with the matron, it was revealed that service users received a range of health care services according to their need. Documentation revealed health professionals such as the GP, tissue viability clinical nurse, dietician; continence clinical nurse, dentist etc were regularly accessed to meet the needs of the service users. Inspection of the Medication Administration Records, the Controlled Drugs Register and drug stock levels evidenced that procedures were in place for the receipt, storage, administration and disposal of medicines. All records were correct and stock levels balanced. The storage area for medicines was clean and tidy. One service user was self-medicating at the time of the inspection and the inspector was shown a comprehensive risk assessment for this. The home’s medication policy had been reviewed and dated April 2005. The signature list for members of staff authorised to administer medication was examined and required updating to include the changes to staff that had recently taken place. The temperatures of the fridge in the clinical room, used for the storage of certain types of medication were seen to be checked each week and recorded accurately. The inspector was shown the registration certificate for the licensed waste disposal company used by the home for the transfer of prescribed medication and the associated transfer notes. A discussion took place between the inspectors and the matron and general manager regarding the content of an end of life plan for those service users who might require it and the need for palliative care training. Each care plan examined showed the wishes of the service user in terms of when they died, however, it was felt that this should be further developed into an end of life plan for those who needed it in conjunction with relatives and other health care professionals. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 13 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 & 15 A range of activities and community contacts were available within the home and visitors were welcomed. The meals in this home were good offering both choice and variety and catered for special dietary needs. EVIDENCE: The manager confirmed that an external activities coordinator visited the home twice a week and that they also had a member of staff whose rota included four hours to support service users with activities. An activities book was in place, which detailed a range of activities offered to service users. Five service users and a relative were spoken to about activities within the home. All confirmed that a range of activities were available including chair aerobics, arts and crafts and occasional music entertainment. Some service users felt that the home offered enough activities but others said that there ‘should be more activities like dominoes, cards and bingo’. However, all acknowledged the home was working hard in this area. One relative made comments in a questionnaire sent directly to the Commission prior to the inspection as follows: ‘The home and staff are providing more activities for service users but I would like those that are up and are able, to go out on visits. But I do understand this depends on number of staff’. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 14 During the inspection it was noted that there was a sense of activity within the home with service users talking together, completing jigsaw puzzles, reading, watching television and listening to music. It was also observed that some good and positive friendships had also been formed within the service user group. A mobile library visited the home every 4 to 6 weeks. Regular visitors to the home also included a hairdresser, a local organist and Clergy from a number of denominations. Five service users and a relative all confirmed that there were no set visiting times and that visitors were welcome at any reasonable time. The statement of purpose indicated that there were three cooks and three kitchen assistants involved in ensuring that service user’s dietary needs were met. The cook said that she had worked at Madeley Manor for 10 years. The cook stated that nursing and care staff passed on information regarding any service user’s likes or dislikes as well as information about special diets. It was noted that this information was also recorded within the kitchen. Five service users were spoken with who confirmed that they were offered a choice of meals from a menu system and that the menu was also available on a board within the dining room. The service user comments about the food were all positive including ‘you get a good choice of food’, ‘it’s nice – you can’t fault it’. The dining room was large and comfortably furnished and the mealtime was noted to be relaxed and informal. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 15 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 17. The home had a satisfactory complaints system and service users felt that their views were listened to and acted upon. Service users were enabled to exercise their legal rights and participate in the electoral process. EVIDENCE: The statement of purpose and service user guide contained appropriate information on how to complain. A complaints procedure was also posted on the wall in the reception area. No formal complaints had been made to the home or to CSCI in the last 12 months. The home had a record of all minor grumbles, which staff sought to address in a timely and effective way. The service users spoken with confirmed that they felt able to air their views and felt confident that any issues would be addressed. The service users also said that the management style within the home was open and that the manager and/or the general manager were always available if they had any concerns. One relative in a completed questionnaire sent directly to the Commission prior to the inspection confirmed that he had made a complaint in the past but these were ‘Minor problems only which were readily resolved’. Discussions with staff highlighted that service users were supported to take part in the political process and enabled to vote in elections. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 16 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): 20, 21 and 23. The internal communal areas were generally, very well maintained and provided bright, homely and comfortable environments for the benefit of the service users. Externally, the communal areas had been made more accessible for those living in the home. There were adequate toilet and washing facilities and the size and layout of the bedrooms were sufficient to meet the needs of the service users. EVIDENCE: The quiet lounge had recently been redecorated to a very high standard with new carpet and armchairs put in place. New curtains were due to be hung in this room which provided a beautiful, calm environment for service users who wished to have peace and quiet. The dining room was in need of some slight refurbishment and the general manager confirmed that this was due to be done after Christmas this year and a new dresser planned to complement the room once the decorating was finished. More bedrooms had been decorated since the last inspection and this had also been carried out to a high standard. The member of staff responsible for the Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 17 maintenance of the building should be commended for the quality of work that has been carried out in and around the home. 8 bedrooms had new carpets and 10 bedrooms had new curtains. A variety of items had been purchased for the benefit of the service users – over bed tables, hospital beds x 2, divan beds x 3, bed rails and bumpers, mattress overlay, pressure relieving mattress, bedroom chairs x 2, towels, face cloths, bedding, cutlery, crockery, gazebo, parasols etc. Most rooms had en-suite facilities and the shared toilets and bathroom facilities within the home were accessible to service users, close to communal areas and clearly marked. The home was extremely clean and a credit to the domestic staff in the home. The grounds around the home were well maintained and provided a pleasant view for the service users. Recently, a patio area with chairs and planters had been provided to enable service users to sit outside and enjoy the outdoors. Also new seats and planters had been donated and placed outside the main entrance of the home and attractive hanging baskets were in place. The inspectors discussed the possibility of the risk to service users falling down the bank around the patio area with the general manager who confirmed that service users were never outside without supervision. Further work was intended to take place in the grounds at the rear and side of the home and it was confirmed that some sort of fencing around the patio area would be considered as part of the changes. An area of broken/uneven slabs was considered unsafe and the general manager on request immediately took steps to prevent access to this area by service users and staff. The dimensions and layout of the bedrooms provided accessible room on either side of the bed for staff and equipment as required. Shared rooms were only occupied by no more than two service users who had made a positive choice to share with each other. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 18 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): 28, 29 and 30. There was appropriate vetting and training of permanent staff to ensure that they were fit and competent to do their jobs. However, vetting procedures for agency staff required further attention to appropriately safeguard service users within the home. Training processes needed to be more robust to ensure that staff remained skilled and proficient in their jobs. EVIDENCE: The manager stated that the qualifications of the staff working within the home included: 3 qualified nurses, one member of staff working towards NVQ3 and five staff members in the process of completing NVQ2. In total 57 of care staff were working towards NVQ2. One relative in a questionnaire told the Commission that she was very pleased with the knowledge that staff had about their jobs at Madeley Manor. Four staff personnel files were inspected. It was found that they contained the necessary documentation confirming that they had been vetted appropriately with CRB, references and identification being in place. Application forms were also in place, which outlined employee’s employment records. At the time of the inspection the home’s rotas indicated that a number of agency staff were being used. The vetting procedure for these staff was discussed with the manager and the general manager. CRB clearances were clarified at the time of the inspection but no other recruitment information relating to these staff was available within the home. It is recommended that the home review the vetting procedure for agency staff to safeguard the service users in the home. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 19 The training file was examined and a variety of training had taken place for staff. However, it is recommended that a training matrix be developed in order to provide a clear tracking process of training that had been completed and to include any proposed dates for future training. It is also recommended that training be provided for all staff on infection control, dementia and abuse awareness. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 20 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, 32, 33, 34 and 35. The registered care manager was fit to be in charge and there was an open and positive atmosphere within the home for the benefit of the service users. Service users and staff were encouraged to attend group meetings to effectively contribute to the running of the home. Financial recording within the home needed to be more robust to safeguard staff, service users and their families. EVIDENCE: Records and discussion evidenced that the registered care manager was a competent, professional and experienced person who was in the process of completing the Registered Manager’s Award and had undertaken a variety of training to ensure that she continued to update her skills and knowledge. She was ably supported by a similarly competent and professional general manager who had worked at Madeley Manor for over 9 years. Between them, they worked in partnership to maintain a high standard of service and promoted an Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 21 open and positive approach creating a relaxed and inclusive atmosphere within the home for the benefit of the service users. The Commission received a significant number of completed questionnaires from service users, relatives and other health and social care professionals regarding the standard of care at Madeley Manor Nursing Home. The comments within these, discussions with service users and relatives, and direct observation evidenced that the style of management ensured that the well being of the service users remained the priority at all times. One relative wrote ‘My family and I are very satisfied by the standard of care provided for my mother at Madeley Manor’. One health professional stated ‘Excellent support from senior nursing staff. Good standards of care provided’ and a social worker wrote ‘Beautiful surroundings, clean, tidy, pleasant atmosphere, friendly, approachable staff, everyone appears to be well cared for’. Regular service user group meetings took place every 4 to 6 weeks and records showed that action was taken almost immediately to meet service user requests. One example of this was that service users had asked for all staff to wear badges with their photographs, name and job title on them. The inspector was shown these badges, which were as a direct result of service user requests. The general manager also consulted with individual service users via a questionnaire and an inspector examined a number of these. Comments seen in these were: “Couldn’t do better, everything is really nice”, ‘Staff are helpful and work hard’, “Drinks could be warmer at night” and “Can’t find any faults, so all is done well”. Other records evidenced that regular staff meetings took place and staff were invited to contribute to the agenda prior to the meeting taking place. It was observed that minutes were taken and feedback provided for staff. The home had lost a significant amount of staff since the last inspection for a variety of reasons and had been using agency and bank staff to cover the shifts, however, some new staff were in place. It was felt by the inspectors that this staffing problem had created significant pressure for the registered care manager and the general manager as well as other staff, which had been managed very well. A discussion took place regarding the involvement of other staff in the progression of the care planning processes to promote ownership and understanding. Records of service user’s personal allowances were examined and found to balance with monies held. However, it is recommended that a receipt be given for every financial transaction taking place within the home and when responsibility for valuables transfers from service user or relative to the home and vice versa. A certificate of insurance was on display within the home and covered legal liabilities to a minimum of £5 million. Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x X 4 3 X 3 X X x STAFFING Standard No Score 27 x 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 3 3 X X x Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 23 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP1 OP7 Good Practice Recommendations For the Statement of Purpose to be updated in terms of staff numbers. Care planning processes to include risks and associated risk assessments which are easily identifiable for staff to ensure that all aspects of health and safety are maintained at all times. The signature list for members of staff authorised to administer medication needs to be updated to include the changes to staff that have recently taken place. The manager should review the vetting procedures for agency staff. To develop a training matrix to provide a clear tracking process of training that has taken place, and to include any proposed dates for future training. Also to provide training for all staff on infection control, dementia and abuse awareness. 3. 4. 5. OP9 OP29 OP30 Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Madeley Manor Care Home DS0000059805.V265119.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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