Inspection on 21/06/06 for Manchester Court

This inspection was carried out on 21st June 2006.

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

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

Other inspections for this house

Manchester Court 18/11/08

Manchester Court 07/11/07

Manchester Court 03/01/07

Manchester Court 17/03/06

Manchester Court 30/08/05

Manchester Court 14/03/05

Manchester Court 03/11/04

Manchester Court 26/03/04

Similar services:

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Fairfields Country Rest Home

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Manchester Court 77 Clarence Street Cheltenham Glos GL50 3LB Lead Inspector Mr Tim Cotterell Key Unannounced Inspection 21st June 2006 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 Manchester Court DS0000016498.V300458.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. Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manchester Court Address 77 Clarence Street Cheltenham Glos GL50 3LB 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) 01242 523510 Raynsford Cheltenham Limited Mr Nicholas Allan Yorke Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Old age, not falling within any of places other category (10) Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th March 2006 Brief Description of the Service: Manchester Court is a listed building in the centre of Cheltenham. It is near to the town centre with all its amenities, and central library and museum are a hundred yards away. The Parish and Roman Catholic churches are near by. Accommodation is on four floors. The kitchen, laundry and some storage areas are in the basement. On the ground floor is the communal dining room and lounge. A shaft lift and stairs serve all residential floors. The bedrooms are located on all floors and are for single occupancy. There are no ensuite facilities, although washbasins are provided in each room. There is level access to the rear of the building, which opens onto a courtyard with some adjacent car parking spaces. The front door has three steps down and opens directly on to Clarence Street. The charges of the home are £270 per week and there are no additional charges. The home has a Statement of Purpose and a Service Users Guide and they provide the information which is required for new and existing service users The home will ensure that service users are kept up to date by providing them with the most recent inspection report. There is a notice board in the home and minutes of the service users meetings are available. Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The inspection was undertaken over two days by two inspectors and they were assisted by one of the Commissions’ pharmacists for a part of the inspection. All of the service users were seen and spoken to. A number were seen individually the others in the communal lounge. All of the care staff on duty were seen and spoken with. The registered manager was also on duty and was involved in the inspection process. It was clear that some improvement had been made and this included some decoration and replacement of furniture. The Company now employs a handyman who is in the home during the week and it is anticipated that repairs and decoration will be undertaken over a shorter period of time than has been experienced. Concern continues to be raised over the failure to meet the minimum staffing level which was required earlier this year and also over the failure to undertake minimum checks when staff are appointed. It was evident that staff are anxious to provide a caring and flexible service but can only achieve this goal if there are enough staff on duty and that they are trained in the areas needed, some of which are mentioned in this report. A number of the requirements in this report have been required previously. A CSCI pharmacist inspector inspected Standard 9 (Medication) to monitor progress following previous pharmacist inspections in 2005. Medicine stocks and storage arrangements, Medication Administration Record (MAR) charts and other records and procedures relating to medication were looked at. The manager and one other member of staff were spoken to. The pharmacist inspection took place on a Wednesday over a 5 ½ hour period. What the service does well: Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 6 Staff have an excellent relationship with the service users and were seen as patient and caring and attempting to provide a personal and flexible service, which would meet the needs of the individual. The home makes great efforts to ensure that service users are able to pursue individual life styles during the day. What has improved since the last inspection? What they could do better: The home must ensure that the required checks are undertaken on all new appointments. The activities should be reviewed and individual interest taken into account when a programme is drawn up. A number of bedrooms were seen as in need of repairs, decoration, and carpet cleaning/replacement. This is the case at each inspection and the home should consider how they cam ensure the matters are addressed in a timely manner. The CSCI will consider enforcement action if improvements to the environment are not made and maintained. Please contact the provider for advice of actions taken in response to this Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manchester Court DS0000016498.V300458.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 Manchester Court DS0000016498.V300458.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): 3 6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Assessments of need are comprehensive and include, where appropriate, mental health issues EVIDENCE: Two pre admission assessments were seen and where applicable any mental health needs were assessed by Gloucestershire Partnership Trust and incorporated into the general assessment of need. Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8. 9,10 Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. The care plans had improved but the omissions meant that service users and staff could be at risk. Quality in this outcome area regarding medication is poor. This judgement has been made using available evidence including a visit to this service by a pharmacist inspector. There are arrangements for the management of medicines but the inspection found these were not always effective and some issues and poor recording could affect the safety and wellbeing of residents. There are some plans to improve systems that should be put in place quickly. Service users dignity may be compromised if care plans are not specific. EVIDENCE: There were 16 service users accommodated, one service user was in hospital. Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 11 Four care plans were looked at in detail. A new service admitted in April did not have a care plan. This is poor practice and a plan should have been recorded. There had been improvements in the care plan format for most service users, and regular monthly reviews were recorded, however there were no comments to say if the care plan had worked well. Generally the needs of the service users were identified but there was insufficient detail in the actions for the plans to help the care staff. One service user who had to remain non-weight bearing due to a fracture did not have a plan of care to help the care staff meet his needs. During the inspection the service user was seen walking without supervision. A care plan for managing challenging behaviour could be more specific and could incorporate the actions identified in the last Care Programme Approach. Some risk assessments were recorded but there was none for a service user who hit another service user, and the action care staff should take to try and prevent this happening. The care staff have experience in caring for the service users and know them well, but need direction and supervision to ensure everyone in the home is safe and their needs are met. It was evident however that care staff need training in managing challenging behaviours. There was a good risk assessment for a service user who falls, however she baths alone and the radiator in the bathroom was not guarded to ensure the her safety. The daily records were generally good and contained details of the service users day. There were no social histories recorded although the care staff knew about some of the service users lives. The social histories would help staff know the service users personal preferences when organising activities and may help them understand some of their mental health problems. Healthcare records were recorded in red in the daily records in one plan, but another plan had none even though the service user had been admitted to hospital, and a physiotherapist had visited on return from hospital. The Care Programme Approach for one service user was due on 13 March 2006 and had not been completed. The service user has challenging behaviour, sometimes at night and the night care plan still did not address what the care staff should do in difficult circumstances. The home now has a medicine trolley but this needs to be brought into use so that the way medicines are given to residents is improved. Another medicine cupboard is in place but more storage is still needed, as some storage arrangements seen in the basement and filing cabinet are not suitable. Using the medicine trolley for routine medicines can create more space. This must Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 12 be fixed securely to the wall when not in use. There is suitable storage for fridge medicines. Storage for controlled medicines complies with regulations. A liquid painkiller kept for one resident should also be kept in this cupboard. A controlled drug record book should be used as part of the records and checks for this class of medicines and similar items discussed at the inspection. The manager ordered this during the inspection along with a new medicine reference book (BNF). The pharmacy provides printed medicine administration records each month. Allergy boxes are completed and photos kept with the charts. Changes to medicines used must be made in a new section and not by crossing out or altering an existing section, as this is confusing. Staff must sign handwritten entries with a signed check by a second staff member that it is correct. Some new medicines in use were not added to charts. Discrepancies were seen on a chart for one resident who receives some medicines via the hospital rather than the pharmacy. Records need to indicate if refused doses are wasted, as this may be an explanation for some discrepancies between records and medicines remaining in stock. There is a method to record what medicines are received into the home but some medicines were missed and not recorded. Records of unwanted medicines returned to the pharmacy are kept. Some entries do not list full details – just the names of the residents. Dates of opening containers for use are not written on medicines (as is included in the policy) so correct stock rotation and audits are not possible. The majority of checks on medicines in the monitored dose system (MDS) blister packs in use appeared satisfactory but nine examples were noted where records did not agree with tablets remaining in the packs. This may be because records are not accurate or residents may not have received their medicines according to the doctors’ instructions. Three recent antibiotic courses were checked as correct on the records. There are no written plans describing the use of any medicine prescribed ‘as required’. One particular resident has various needs for painkillers but there is no plan to describe the range of doses to use. One dose the previous day was in excess of the prescription although the staff said the doctor had authorised this but there was no evidence for this. The same resident looks after and self-administers a number of medicines. A locked cabinet is provided in the bedroom but this is not large enough for all the medicines used. There was no risk assessment or care plan about this. Doses for two different insulin products were not defined in any records. There is secondary dispensing of medicines into a weekly box, which is not safe. The box is not labelled and records are not made when the medicines are given to the resident to look after. Various options were discussed to improve these arrangements and more safely meet the needs of the resident. A cream and a medicine spray were found in two other rooms. Staff on duty were trained about the safe handling of medicines. The evidence from the inspection indicates staff are not always carrying out the safe practices in which they have been trained. There is a medicine policy and procedures in the office reviewed in May 2005 but this does not include Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 13 comments made in a previous inspection report as not all issues needed are covered. Procedures also now need to deal with the proposed improved method of giving out medicines using a trolley, use of controlled drug record book and self-administration now in place for one resident, for example. All staff need to made aware of and have training about the standards the home expects for handling medicines. The manager needs to regularly monitor staff adherence to safe procedures and demonstrate residents are having their medicines safely by recording medicine audits and checks for accurate records being made. Service users and relatives who completed the questionnaires provided by the Commission stated that they were treated with dignity and that staff were caring and sensitive. Manchester Court DS0000016498.V300458.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 adequate. This judgement has been made using available evidence, including a visit to this service. Service users are able to have visitors and experience a degree of choice over their daily lives. There is sufficient food which is well presented but a greater choice would be welcomed. EVIDENCE: It was evident that the service users who able to indicate their wishes could enjoy a degree of choice and independence in their daily lives. This included choice about when they got up and went to bed and where they had their meals. The home has an activities schedule, which delegated different days to different members of the care staff. There are several issues that arise form the current arrangements. The home expects the member of care staff to undertake the activities but unless the minimum level of staff are on duty it may be difficult to undertake an activity without the need for the staff member to be covering other duties e.g. supervision of another service user. The activities schedule was brief and appears to leave a lot of the detail to staff. As staff have not been trained to provide activities this must be considered and Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 15 more time and effort given to the planning process to ensure activities are appropriate and that staff have the skills and time to do them without interruption. There were no activities on the day of the inspection. Friends and families are made welcome and the relatives seen felt comfortable when they visited saying that staff were helpful and understanding. All staff who prepare food have received training in food hygiene. The kitchen had no extraction system and whilst the temperature was not determined they should be monitored to ensure people who use the kitchen have a safe and pleasant environment. The menu operates on a weekly basis and could be considered as limited in choice and did not identify any options. However staff informed the inspector that options are always available if requested. It is recommended that service users have advance notice of the main meals to ensure they have time to exercise choice. The current system of staff knowing dislikes is commendable but is not the same as service users being able to actively choose an identified alternative. Hot and cold drinks are available throughout the day. Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 adequate. This judgement has been made using available evidence, including a visit to this service. Service users can only be protected from abuse if staff are aware of the various forms it takes EVIDENCE: Service users and relatives who were seen said that they are able to approach staff and the manager and that any concerns would be brought to their attention. The home has a written complaints procedure but it was felt that service users are likely to take a more informal route, which may include raising any concerns through the service user meetings. A number of the staff had a limited understanding of what is considered to be “abuse” and require formal training to ensure they are clear about what constitutes abuse. Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Whilst some improvements have been made the home has not maintained a reasonable standard in some of the accommodation used by service users EVIDENCE: Lower Ground Floor The stairway between the ground floor and the kitchen needs cleaning and decorating. Ground Floor The communal areas were inspected and this included the lounge and dining rooms. Some of the furniture has been replaced and the range of armchairs Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 18 means that some of the “older” service users have more options about what they are able to use. Bedroom 1 Medicines are held in this room but were not kept locked up and others service users could enter the bedroom. The service user must have a locked facility to ensure safety of the medicines. The carpet must be cleaned or replaced. Bedroom 2 The carpet must be replaced. The outside of the windows were dirty. Second Floor Bedroom 18 The ceiling is stained. The door needs a more appropriate mechanism to lock from the inside as the present arrangements may present difficulties in an emergency. Bedroom 17 The carpet must be replaced. The window is not restricted. The room needs decorating. Bathroom/toilet The top of the toilet is cracked and the wall needs decorating. Bedroom 22 One window is not restricted. The door closer needs attention. A new lampshade is needed. First Floor Bedroom 12 Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 19 The carpet needs cleaning. The dressing table should be replaced due to its poor condition. Toilet No toilet roll holder, no shade and no working vent. Furniture must not be stored in the corridor. Lounge Considerable improvements and this now provides a pleasant environment. Bedroom 8 Requires a locked facility for the medicines held in this room. Outside areas The attention of the registered manger was brought to the access and steps, which lead to the lower ground floor. There are three separate entrances which are all accessible to the service users and the inspectors felt that the areas must be risk assessed and if appropriate the potential risk of falling to be reduced by some measure. The registered manager has agreed to look at this as a matter of urgency. Manchester Court DS0000016498.V300458.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is adequate. The home will not be able to meet the needs of the service users unless adequate staff as indicated in this report are provided. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The minimum number of staff on duty during the waking day did not meet the required `level as set out in the last inspection report (see page 16 of the inspection report dated 17 March 2006). The registered manager stated that a number of factors had prevented this minimum being reached during the morning and afternoon shifts on the day of the inspection but that recent recruitment would ensure that this would not be repeated. The minimum set after the March 2006 inspection is not an ideal figure based on individual needs but rather from a figure based on what would be required to provide a minimum level of supervision. If the minimum figure is breached on a further occasion formal action may be taken. A recent appointment had been made and whilst references had been taken up there was no evidence of the CRB/POVA disclosure, this practice contravenes the legal requirements (regulation and National Minimum Standards). No future appointment must be made before, as a minimum, POVAFIRST checks are made, followed by a CRB disclosure. The registered manager was advised how to obtain the POVAFIRST check. If any appointment are made using this system the Commission must be consulted. It is the responsibility of the Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 21 Registered Person to ensure that proper recruitment practice is followed to protect service users in their care. Some of the staff on duty had not received any formal training in the identification of abuse. None of the staff seen had received any formal training in meeting mental health needs. It may be helpful to contact Gloucestershire Partnership Trust, Charlton Lane Centre, Cheltenham who are responsible for the service to “working age adults” who have mental health problems. They have considerable experience with the problems experienced and may be able to advise or indeed offer some form of direct training to staff. There is no doubt that some staff at Manchester Court have little knowledge of the complex problems and management issues presented. The Trust have indicated that they look forward to hearing from the Registered Manager. The inspectors felt that staff were anxious to provide a safe, caring and stimulating environment, but that this could only be achieved with adequate training and sufficient resources. The registered manager is solely responsible for the short listing and interviewing of staff and services users play no active part in this process. It is recommended that all care posts are advertised and that staff and service users should be consulted over how they could play a part in the recruitment procedures. Manchester Court DS0000016498.V300458.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The registered manager provides an open and transparent management style which enables service users to influence the quality of their day to day lives EVIDENCE: Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 23 The issue of the responsible individual was raised and the question of whether the registered manager can undertake this on behalf of the company. The inspector will seek the legal advice from the Commission and report back to the manager. Some concern was expressed by the inspectors over the failure of the registered manager to be aware of some of the areas of concern identified on the day of the inspection specifically the physical environment; an example would be the condition of some of the carpets. It was suggested that the home devise a system where there is a thorough and regular check made to enable concerns to be identified and action taken without the need for the Commission to constantly report matters when inspecting. The registered person is responsible for ensuring that the environment complies with Regulations. The Commission will \consider taking formal action if improvements are not made. The inspectors were advised that the registered manager had completed a risk assessment of the building as required by the Fire and Rescue Services. However concern was expressed over the failure to note and reduce the risks in respect of the access to the cellar level and the potential danger for any service users who may inadvertently use the steps. In order to ensure a safe environment is provided and maintained it is essential that all window openings are risk assessed and that where appropriate restrictors are fitted and then maintained in working order. Staff supervision is undertaken through the homes regular staff meetings The registered manager undertakes an annual quality assurance through questionnaires, and this includes consulting service users relatives and visiting health professionals. When the results have been collated and analysed it would be helpful if a copy was forwarded to the Commission. Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 X X X X X x 2 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2. 3 4 5 Standard OP12 OP7 OP15 OP18 OP19 Regulation 16 15 16 18 23 Requirement The home must ensure staff are trained in providing activities All care plans to be completed. Care plan assessment to have detailed day/night action plans Service users must have an identified choice when meals are provided Staff must be trained in the identification of abuse The home must undertake the repairs, replacements, cleaning and decoration as indicated in the main body of the report The home must ensure recruitment procedures as laid down in the regulations are followed Provide suitable and safe secure storage for all medicines. Medicine administration methods must be safe and follow the guidance from the Royal Pharmaceutical Society Keep complete and accurate records for the receipt, administration and disposal of all medicines with checking systems in place as indicated in the DS0000016498.V300458.R01.S.doc Timescale for action 30/09/06 30/09/06 30/09/06 30/10/06 30/09/06 6 OP29 18 30/09/06 7. OP9 13 15/08/06 8. OP9 13 17 31/07/06 Manchester Court Version 5.2 Page 26 OP9 9 13 17 10 OP27 18 11 OP30 18 report. Administer medicines to residents according to doctors’ directions. Risk-assess and make safe arrangements and records for the self-administration of medicines for a particular resident. Implement written protocols describing the use of any medicine prescribed ‘as required’. Previous requirement for 30/05/06. The home must meet the minimum staffing levels Previous requirement for March 2006 The home must ensure all staff have the training as indicated in this report i.e. mental health needs/challenging behaviours. 31/07/06 21/06/06 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4 5 Refer to Standard OP9 OP9 OP9 OP27 OP30 Good Practice Recommendations Use a controlled drug record book to improve records for this class of medicines. Carry out and document regular medicine audit counts and checks of staff to demonstrate the correct use and recording of medicines. Review and update the medicine policy and procedures. Make all staff aware of this and monitor their adherence to and understanding of it. The home must submit a complete staff rota The home must submit staff training profiles Manchester Court DS0000016498.V300458.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Manchester Court DS0000016498.V300458.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!