Inspection on 19/09/06 for Palatine Lodge

This inspection was carried out on 19th September 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

Palatine Lodge 20/05/09

Palatine Lodge 26/11/08

Palatine Lodge 02/01/08

Palatine Lodge 11/07/07

Palatine Lodge 23/02/06

Palatine Lodge 11/10/05

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

CARE HOMES FOR OLDER PEOPLE Manderley Residential Care Home 17/19 Palatine Square Burnley Lancashire BB11 4JF Lead Inspector Mrs Julie Playfer Unannounced Inspection 19th September 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 Manderley Residential Care Home DS0000064567.V312603.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. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manderley Residential Care Home Address 17/19 Palatine Square Burnley Lancashire BB11 4JF 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) 01282 431450 Dr Morgiana Muni Nazerali-Sunderji Care Home 15 Category(ies) of Dementia (10), Learning disability (5), Mental registration, with number disorder, excluding learning disability or of places dementia (10) Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must employ a suitable qualified and experienced manager who is registered with the Commission The home is registered for a maximum of 15 service users to include: Up to 10 service users in the category of MD Up to 10 service users in the category DE Up to 5 service users in the category LD No new service users under the age of 55 years will be admitted to the home. 23rd February 2006 3. Date of last inspection Brief Description of the Service: Manderley is a large 2 - storey Victorian style property, situated close to the town centre and its amenities and bus stops. The garden areas are ramped to allow easy access for residents. Accommodation consists of 11 single and two double rooms. As a home in existence prior to the implementation of the National Minimum Standards in April 2002, Manderley was exempt from having to meet some of the Standards relating to room sizes. The upper floor is accessed via a stair lift. There is equipment and adaptations available to assist the residents with mobility problems. All rooms are linked to the call system. At the time of the inspection, the scale of fees ranged from £310.50 to £562.06. Additional charges were made for hairdressing (£6 - £23), chiropody (£10 - £16), toiletries and activities outside the home. Information was made available to prospective residents by means of a statement of purpose and service users guide. The service users guide was usually given to prospective residents and/or their relatives on viewing the home or at the point of assessment. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was unannounced and took place over eight hours on 19th September 2006. The purpose of the inspection was to assess important areas of life in the home and check progress made to meet previous legal requirements and recommendations. The lead inspector was accompanied by a new inspector for the puposes of induction. At the time of the inspection there were 14 residents accommodated in the home. The inspection comprised of spending time with the residents, looking round the home, looking at residents’ care records and other documents and discussion with the staff and the manager. Three residents were involved in the case tracking process. Prior to the inspection the manager completed a questionnaire, which provided useful information and evidence for the inspection. Comment cards were sent to the home for residents and their relatives. 4 cards were returned from relatives/visitors to the home. What the service does well: Prospective residents were encouraged and supported to visit the home prior to admission. This provided the opportunity to meet the other residents, have a look round the home and sample the meals. The admission procedures included a proper assessment of peoples’ needs. This enabled the registered manager and prospective residents to determine whether or not the home could meet their needs. Residents spoken to felt they received a good standard of care and the staff respected their rights to privacy and dignity. The residents described the staff as “nice” and said “they are very good”. The daily routines were flexible and designed to meet the wishes of the residents. One person said “I like to go to bed early and get up early” and another person commented “I really like sitting in my room watching television”. Activities were arranged in line with the needs and preferences of the residents, which included regular trips out in the local area. The home provided varied and well-presented meals. All residents spoken to described the meals as “very good”. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 6 Residents were provided with clean and nicely decorated bedrooms. The residents could personalise their rooms with their own ornaments and small items of furniture. The sitting and dining areas were decorated in a homely and comfortable fashion, with a variety of armchairs, footstools, side tables, ornaments and wall pictures. A good percentage of the staff had achieved NVQ level 2; this qualification provided the staff with the necessary training to carry out their role effectively. What has improved since the last inspection? What they could do better: The residents must be provided with clear up to date written information about the home, so that they are aware of the services and facilities provided. All residents must also be supplied with a contract and a revised complaints procedure. This will provide the residents with knowledge about the terms and conditions of residence and details about whom to raise a complaint or concern. One care planning format should be adopted and implemented. This will promote consistency and make it easier for the staff to read and understand. The residents must be more involved in the care planning process and the plans must be reviewed every month. Risk assessments must also be carried out in respect to moving and handling and nutrition, to ensure any risks are identified and managed. To further promote the comfort of the residents, repairs must be made to the lounge window and wardrobes. In order to fully protect the residents the vulnerable adults procedure must be updated and the recruitment and selection of new staff must be improved. To assure the health and safety of residents, the gas systems and the portable electrical appliances must be tested and the safety certificates renewed. In addition, a first aider must be on duty at all times, including during the night. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 7 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. Manderley Residential Care Home DS0000064567.V312603.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 Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ needs were appropriately assessed and residents were encouraged to visit prior to admission, to assess the quality, facilities and suitability of the home. However, the residents were not provided with up to date information about the services and facilities of the home. EVIDENCE: Written information was available for residents in the form of a statement of purpose and service users guide. However, both documents had not been updated in line with regulatory requirements and the change of manager. The service user guide had not been supplied to service users. It was evident from the case tracking process that not all residents had been issued with a contract. The records of the two most recently admitted residents showed that a social work assessment had been received prior to admission. In addition, the registered provider had undertaken an in-house assessment of one person’s Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 10 needs, which was detailed and comprehensive. This assessment covered the person’s personal, social, healthcare and mental health needs and provided significant information for staff. One resident visited the home on two occasions, prior to admission, with her social worker. This provided the opportunity to discuss her needs, meet the staff and residents and view the vacant room. Manderley did not provide intermediate care. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The care planning systems addressed the needs of the residents and provided guidance to staff on how these needs were to be met. However, the use of one care planning format would further promote consistency and ease reference for staff. Appropriate arrangements were in place for the management of medication in the home. EVIDENCE: From the case files seen it was evident that each resident had a comprehensive plan of care based on their assessment of needs. The plans were detailed and provided staff with guidance on how to meet the diverse needs of the residents. However, the format used for care planning was different in each file and there was no evidence to indicate that the residents had been consulted or involved in devising the plans. There was evidence of review, but this had not always been carried out on a monthly basis. Two residents had an essential lifestyle plan, which was seen as an area of good practice. The care plans were supported by the records of personal care, which provided information on changing needs and any recurring difficulties. However, these Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 12 records focussed on significant occurrences and observations and had therefore not been maintained on frequent basis. For instance, there was a gap of twenty days in one person’s personal care records. It was noted that a chart had been implemented to record personal care, however, this did not provide detailed information about a person’s well being. Health care needs were addressed in the care plans and all residents were registered with a doctor. The records of personal care indicated that the residents had access to NHS services. Appropriate risk assessments had been carried out in respect to the potential risks associated with general well-being, mobility and behaviour. The assessments included management strategies in order to minimise or eliminate any identified hazards. However, a moving and handling risk assessment had not been carried out in respect for one person’s needs. Nutritional risk assessments had also not been carried out. A chart was maintained to monitor weight, however, the recording was sporadic. The residents spoken to felt the staff respected their right to privacy and all made complimentary remarks about the staff, for instance one resident said the staff were “very nice”. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term of address. The home operated a monitored dosage system for the administration of medication, which was dispensed into cassette trays. Policies and procedures were available, but these had not been personalised in line with the procedures operational in the home. Appropriate records were in place to record the receipt, administration and disposal of medication. Any changes or discrepancies with the medication had been checked with the pharmacist or doctor. However, it was noted that protocols had not been devised for all medication prescribed as necessary. At the time of the inspection, the manager and six members of staff were undertaking a Safe Handling of Medication course. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 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, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were able to choose their life style and social activity and were supported to keep in contact with their friends and family. Residents received a healthy and varied diet according to their assessed requirement and choice. EVIDENCE: The residents said the daily routine was flexible and they were able to get up and go to bed at a time of their choosing. One resident said “I like to go to bed early and I like to get up early”. Residents had a range of opportunities to pursue activities both inside and outside the home. A comprehensive file of social activities had been maintained by the home. Activities inside the home included, Christmas card making, colouring, film nights, sing-a-longs, manicures and bingo. Residents were also involved in activities outside the home, which included going to the luncheon club, shopping, going out to cafes and the cinema. One resident told the inspector that she hadn’t been out recently. However, on examination of the person’s records, it was evident the person had been on several outings from the home. Further to this the manager reported that wherever possible, an extra member of staff was placed on the rota at weekends to facilitate outings. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 14 There was no evidence to indicate that formal residents’ meetings were arranged in the home. However, the residents were consulted informally as part of the daily life in the home, especially in respect to their choice of food and activity. There were no restrictions placed on visiting and the residents were able to entertain their guests in private. All the relatives who completed a comment card indicated that they felt welcome in the home and were satisfied with the overall quality of care provided. One person also commented that the “staff are very friendly”. Residents were encouraged to exercise choice and control over their lives. As such residents were supported and assisted to manage their finances. Residents were also able to bring in personal belongings and arrange their rooms how they wished. The residents were provided with three main meals a day and the choice of meals was discussed prior to each meal. The residents were satisfied with the quantity and variety of meals and described the food as “very good” and “excellent”. Drinks and snacks were available at set times throughout the day and evening and at all other times on request. A detailed record of meals served to residents was maintained. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 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 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Systems were in place to ensure any complaints would be taken seriously and acted upon. Staff would benefit from clearer information and training in respect to the protection of vulnerable adults. EVIDENCE: A complaints procedure was included in the service users guide and statement of purpose. However, this required amending in respect of the information pertaining to the Local Government Ombudsman, which is no longer applicable and the contact number of the registered provider. A pictorial version of the procedure was displayed in the residents’ bedrooms, however; this procedure also required updating. The residents spoken to said they were aware of whom to speak to in the event they wanted to voice a concern and felt that the their concerns would be listened to. Since the last inspection a copy of the complaints procedure had been sent to the residents’ relatives. The home had received three complaints, which had been investigated by the manager and the registered provider. Details of the complaints were available in the home, however an overall record of complaints was not seen. A copy of “No Secrets in Lancashire” (The Joint Strategy for the Protection of Vulnerable Adults) was available, along with a specific procedure setting out the required response in the event of any allegations or suspicion of abuse. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 16 However, the internal procedure was difficult to follow and did not include contact details of the relevant agencies or make reference to the lead roles of Social Services and the Police. A whistle blowing policy was in place. However, staff had not received specific training in respect to adult protection protocols and not all staff were familiar with the procedures. Manderley Residential Care Home DS0000064567.V312603.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, 20, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The residents were provided with a clean and comfortable environment, however, the lack of keys for their bedroom doors and lockable facilities compromised their right to privacy. EVIDENCE: Manderley is a mature property situated in its own grounds. The home is located within a mile of the town centre. Accommodation is provided in 11 single bedrooms and 2 double rooms, none of the bedrooms have an ensuite facility. The first floor is accessed by a stair lift. Communal space is provided in two lounges and a dining room. The residents had access to gardens, which included seating areas. It was evident from a tour of the home that residents had personalised their rooms with their own belongings and decoration was good throughout. The residents said their rooms were comfortable and warm. One resident said her room was “lovely” and added, “I like my room so much I wouldn’t like to change it”. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 18 It was noted that a child’s safety gate had been fitted on the landing of the first floor, which impeded free access and exit to two bedrooms. This was removed by the manager during the inspection. At the time of the inspection, the window in one of the lounges was jammed opened and could not be closed. As a result the residents sitting in this room said they felt cold. The top wardrobe doors in two bedrooms, were no longer fixed and some wardrobes had missing door handles. The residents’ bedroom doors were fitted with appropriate locks; however, none of the residents had been issued with a key. Two residents spoken to said, they would like a key to their bedroom door, so they could lock it, when they went out. Similarly, the residents had lockable drawers, but no keys were available. A programme of maintenance and renewal of fabric was available and the manager explained that arrangements had been made to clean the carpets on the first floor. The standard of cleanliness was good in all areas seen. All residents spoken to said the home was kept clean and tidy. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff in the home were trained and in sufficient numbers to meet the needs of the residents. However, the recruitment and induction procedures were unclear and not robust. EVIDENCE: The manager maintained a staff rota, which was completed in advance. From inspection of the rota, it was evident the levels of staffing compiled with previous guidance issued by the Local Authority. The files of three members of staff, who had commenced work in the home, since the last inspection, were examined. All three staff had completed an application form and attended the home for an interview. Two written references and a POVA check (Protection of Vulnerable Adults list) had been obtained prior to employment. However, it was noted that the staff had not supplied a full work history and there were no satisfactory written explanations of gaps in their employment record. A recruitment and selection procedure was not seen and none of the staff had been issued with a copy of the Code of Practice set by the General Social Care Council. Arrangements were in place for the induction and supervision of new staff and one member of staff spoken to, confirmed she was not undertaking personal care tasks until her CRB check was received. However, the induction process was unstructured and informal and the manager explained that plans were in place to introduce the “Skills for Care” induction programme. The manager had Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 20 also devised a training and development plan and had identified future training needs of the staff group. Information contained in the pre inspection questionnaire indicated that 7 members of staff had completed NVQ level 2 or above, which equated to 58 of the staff team. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 21 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, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management and administration of the home is efficient and effective and the service is run in the best interests of the residents. EVIDENCE: At the time of the inspection, the manager was relatively new to the home and had not yet applied to the Commission for registration. The manager had completed NVQ 4 in Care and the Registered Manager’s Award. She had several years experience working in other residential settings and had two years experience of working at a management level. The manager was currently undertaking a safe handling of medicines to update and further her knowledge and skills. The manager was well supported by the registered provider. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 22 Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the staff, who they described as “very nice ” and “friendly”. One resident said, “I can talk to them anytime and have a laugh with them”. A programme of staff supervision had been established and staff meetings were held on a regular basis. The home had achieved Preferred Provider status with the Local Authority. Satisfaction questionnaires had been distributed in 2005 and the results had been collated and a development plan had been devised. Questionnaires had been given to the residents and their relatives in August 2006 and the manager was waiting for survey forms to be returned, so the results could be analysed. Appropriate arrangements were in place for handling money, which had been deposited with the home by or on behalf of a resident. A random check of monies was found to be correct. Records were also maintained in respect to the amount of fees charged and received. There was a set of health and safety procedures available, which included the safe storage of hazardous substances. Staff had received health and safety training, which included moving and handling, food hygiene, fire safety and first aid and there were arrangements in place to update the training. At the time of the inspection, there was not always a qualified first aider on night duty. Documentation was seen during the inspection, which confirmed that electrical and fire systems were tested and serviced at regular intervals. However, it was noted that the gas safety and the PAT (Portable Appliance Tests) certificates had expired. All water outlets were fitted with preset valves and the temperature was tested and monitored with a probe thermometer. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 23 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 2 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 2 X X X 2 X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 X 2 Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 and 5 Requirement Timescale for action 01/11/06 2. 3. OP7 OP7 15 (2) (c) 15 (2)(c) The registered person must ensure the statement of purpose and the service users guide cover the elements listed under standard 1 and meet with regulatory requirements. The residents must be consulted 01/11/06 and involved in the care planning process. The care plans should be 01/11/06 reviewed at least monthly and updated as required. Previous timescale of 31/03/06 not met. 4. OP8 13 (4) (5) 5. OP16 22 6. OP18 13 (6) Moving and handling and nutritional risk assessments must be carried out as appropriate. The complaints procedure must be updated. The information pertaining to the Local Government Ombudsman must be removed and the contact details of the registered provider must be correct and up to date. The adult protection procedure must be updated to make DS0000064567.V312603.R01.S.doc 01/11/06 15/11/06 15/11/06 Manderley Residential Care Home Version 5.2 Page 25 7. 8. OP20 OP24 9. OP29 10. OP30 11. OP31 reference to lead role of Social Services and the Police. Contact details of the relevant agencies must also be included. The staff must receive specific training to ensure they are familiar with the procedure. 23 (2) The window in the lounge requires attention to ensure it fully closes. 23 (2) The wardrobe doors and handles must be repaired as necessary and residents must be provided with keys to the lockable facilities and the bedrooms doors. 17, 18, 19 All records and checks for new schedule members of staff must be 2 collated and maintained in line with the Care Homes Regulations 2001. 18 (1) All new members of staff must complete a structured induction programme, which meets “Skills for Care” standards. 8 Application must be made to register a manager with the CSCI. 13 (4) The gas systems must be tested and serviced and the gas safety certificate renewed. The portable electrical appliances must be tested and the PAT certificate renewed. There must be a qualified first aider on duty at all times. 19/09/06 01/11/06 19/11/06 01/11/06 15/11/06 12. OP38 15/11/06 13. OP38 13 (4) (c) 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000064567.V312603.R01.S.doc Version 5.2 Page 26 Manderley Residential Care Home 1. 2. 3. 4. 5. 6. 7. Standard OP2 OP7 OP7 OP8 OP9 OP16 OP29 All residents should be issued with a contract/terms and conditions of residence. One system and format of care planning should be adopted. The frequency of care records in narrative format should be increased. Records should be consistently maintained of the residents’ weight. Protocols should be developed for all medication prescribed “as necessary”. An overall record of complaints should be maintained, to provide an overview of the number and type of complaints received and a means of tracking complaints. A recruitment and selection procedure should be devised, which covers the requirements of the Care Homes Regulations 2001. Manderley Residential Care Home DS0000064567.V312603.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Manderley Residential Care Home DS0000064567.V312603.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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