Inspection on 02/01/08 for Palatine Lodge

This inspection was carried out on 2nd January 2008.

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 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

Palatine Lodge 20/05/09

Palatine Lodge 26/11/08

Palatine Lodge 11/07/07

Palatine Lodge 19/09/06

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 09:30 2 January 2008 nd 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.V355277.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.V355277.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 manderleymanager@gmail.com Dr Morgiana Muni Nazerali vacant post 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.V355277.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. 11th July 2007 3. Date of last inspection Brief Description of the Service: Manderley Residential Care Home 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 £341.00 to £482.00. Additional charges were made for hairdressing, chiropody, 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.V355277.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Manderley Residential Care Home on 2nd January 2008. Two inspectors carried out the inspection. The previous key unannounced inspection took place on 11th July 2007. There have been three random unannounced inspections since July 2007, one of which was carried out by the Pharmacy Inspector. Reports pertaining to each inspection can be obtained from the Commission on request. At the time of the inspection there were 13 people accommodated in the home. The inspection comprised of spending time with the residents, looking round the home, looking at the residents’ care records and other documents and discussion with the staff, the acting manager and the area manager. As part of the inspection process the inspectors used “case tracking” as a means of gathering information. This process allows the inspectors to focus on a small group of people living at the home to determine an assessment of the quality of services provided. Following the previous key inspection, the registered provider submitted a detailed improvement plan and has kept the lead inspector informed of developments in the home. This information was considered as part of the inspection process. What the service does well: The residents were able to exercise choice and control over their lives. The daily routines were flexible and designed to meet the wishes and preferences of the residents. As such the residents could decide when they wished to get up and go to bed. The residents spoken to felt that the staff respected their rights to privacy and personal care was delivered appropriately. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. The residents were aware of the complaints procedure and knew who to talk to in the event of a concern. Residents’ meetings were held on a regular basis, which gave the residents the opportunity to discuss all aspects of life in the home. The residents were provided with clean and comfortable bedrooms. The residents could personalise their rooms, with their own belongings. The sitting and dining areas were decorated in a homely fashion, with a variety of armchairs, footstools, side tables, ornaments and pictures. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 6 A good percentage of staff had achieved NVQ level 2 or above. This qualification provided the staff with the necessary knowledge to carry out their role effectively. What has improved since the last inspection? What they could do better: The residents must be involved in the development and review of their care plans. This is to ensure the residents have an input into the delivery of their personal care and the staff are aware of their wishes. Risk assessments must include management strategies. The risk assessments must also be kept under review and updated in line with changing needs. This is to ensure the staff are fully aware of how to manage, reduce or eliminate any identified risks. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 7 Following thorough consultation with the residents a programme of activities must be provided on a regular basis. This is to ensure the residents have the opportunity to develop their skills and pursue a variety meaningful activities inside and outside the home. The residents must be consulted and the food provided must be monitored, to ensure the residents receive a variety of wholesome meals in accordance with their individual preferences. Arrangements must be made to ensure the toilet door on the first floor remains closed. This is to ensure the residents’ right to privacy is protected. The home has been without a registered manager since October 2005 and an application must be made to register a manager with the Commission. This is to ensure a person is registered to take legal responsibility for the day-to-day operation of the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Manderley Residential Care Home DS0000064567.V355277.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.V355277.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. At the time of the inspection, residents were provided with written information about the home in a standard format and had limited involvement in the assessment of their needs. EVIDENCE: Written information was supplied to the residents in the form of a service users guide. The residents spoken to confirmed they had received a copy of the guide, but said they had found it difficult to understand. Further to this, a new service users guide had been developed and a draft copy was seen during the inspection. This was written in an easy read format and included pictures to illustrate the text, however, at the time of the inspection, it had not been distributed to the residents. Four personal files were inspected as part of the case tracking process. Contracts were seen on two of the established residents’ files. One contract Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 10 was missing from the relevant section in the file, although it was seen during the last inspection. The contracts included relevant information about the terms and conditions of residence. One resident had moved to a bigger room since the last inspection, this had been fully explained and agreed with the person, in order for his original room to be redecorated and allow him more space for his possessions. One resident had been admitted to the home for short-term care since the last inspection. It was apparent from the records seen that this person’s needs had been assessed with the involvement of the person’s regular carer, on the day of admission. A copy of an earlier social work assessment was also on file. The person had been previously admitted into the home and the area manager reported that a letter had been sent to the person’s carer to confirm the person’s needs could be met. There had been no permanent residents admitted to the home since the last inspection. However, one person was considering leaving the home and it was noted this person was given appropriate support and assistance to enable her to make her decision of where to live. The needs of the residents, who had been established for sometime, had been reassessed and reviewed by the management team as part of new care planning systems. However, there was little evidence to demonstrate the residents had participated in the review process. Manderley Residential Care Home DS0000064567.V355277.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents were not always involved in the development and review of their care plan. The systems in place to manage medication were safe and efficient. EVIDENCE: Since the last inspection, improvements had been made to the care planning system. There were several types of plan seen on each person’s file, all of which provided detailed information about the residents’ current personal and healthcare needs. There was also a summary of the care plans known as a “mini plan”, which was placed alongside the daily care records. This plan provided an informative overview of the residents’ needs and included guidance for staff on how to meet the residents’ needs. The “mini” plans were written in the first person, however, there was limited evidence to demonstrate the residents had been involved in the development of the plans. None of the residents spoken to during the inspection were aware of the care planning documentation and none could recall discussing their needs with a member of staff. This meant there was the potential for residents’ behaviour, thoughts and feelings to be misinterpreted. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 12 Whilst a record had been made of the date the care plans had been reviewed, the review pattern was variable. It was also unclear who had been involved in the review and which section of the care plan documentation had been reviewed. The care plans were supported by the records of personal care, which provided useful information on changing needs and any recurring difficulties. Since the last inspection, other daily records had been introduced. These included a personal care checklist, a nutritional input chart, an overview of activities and care and an activity chart. The residents had been allocated a key worker of their choice, who helped them with daily living tasks. Healthcare needs were addressed in the residents’ “integrated health and social care plan” and included information about the residents’ psychological and mental health needs. All the residents were registered with a General Practitioner and advice had been sought from specialist services as necessary, for instance the District Nursing Team. A chart had been maintained for each resident to monitor any fluctuations in weight. However, according to the records seen, one person had not been weighed since November, despite consistently losing weight over the previous three months. Risk assessments had been carried out in respect of moving and handling, pressure sores and falls. However, risk management strategies had not always been drawn up to provide the staff with guidance on how best to manage and reduce the risks. For instance, there were no risk management strategies seen in respect to the risks identified following a “Waterlow” assessment of the risk of pressure sores. Whilst the area manager reported one person’s moving and handling risk assessment had been reviewed and updated, the risk assessment and risk management strategies were not seen within the person’s care plan documentation. The residents spoken to felt the staff respected their right to privacy and confirmed that personal care was carried out appropriately. However, it was noted that some residents were aware of the various changes in the management and staff teams during the last year and as a result they were in the process of assimilating the changes. One person said, “I’ve not got used to the new manager yet, things are different from before”. The staff were observed to interact with the residents in a positive manner and they referred to the residents in respectful terms. Policies and procedures were available to cover all aspects of handling medicines in the home. Since the last inspection, a weekly audit tool had been introduced, which enabled the manager to check the medication systems and take any action as necessary. This meant any anomalies could be detected promptly. In addition, staff designated to administer medication had completed an accredited training course. Appropriate records were in place for the Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 13 receipt, administration and disposal of medication. All records seen were complete and up to date. Suitable arrangements were in place to store, record and administer controlled drugs. Manderley Residential Care Home DS0000064567.V355277.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. 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. The residents were able to make choices about their life style; however, the activities and food provided did not meet some people’s expectations. EVIDENCE: The routines in the home were well established and residents had a choice in the times they went to bed and got up in the morning. One resident said, “I can do what I like” and another person said, “I’m a early riser and like to get up early”. All the residents spoken to felt that the routines were flexible and they were able to make choices and exercise control. The residents were consulted on an ongoing basis about their choices in daily living and more formally at residents’ meetings. The residents’ preferences in respect of social activities were recorded as part of the care planning process. Since the last inspection, a record of activities had been maintained on a daily basis. The types of activities recorded included, attending luncheon club, watching television, chatting to staff, doing jigsaws and playing dominoes. Information about activities was displayed on a notice board in the dining room. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 15 The residents had mixed views about the type and frequency of the activities provided. One person said there were very few organised activities and another person said the activities observed on the day of the inspection, (games, jigsaws and drawing) had not been arranged for sometime. A member of staff spoken to was aware of the need to support the residents to develop their skills and said the provision of activities, inside and outside the home, was a current area of development. There were no restrictions placed on visiting times and residents were able to receive their guests in privacy of their bedrooms, should they wish to do so. The residents were also supported to visit their families. The residents were provided with three main meals a day and choice of food was discussed prior to each meal. Staff were observed asking the residents what they wished to eat. The meal served on the day of inspection was well presented and looked appetising. However, some of the residents had strong views about the food, one person said, “Lunchtime is not bad, but the tea is a poor do – too many sandwiches” and another person said, “I don’t like anything”. The residents confirmed they had discussed the meals at a residents’ meeting and their views had been recorded, but they felt there had been no improvements yet. The record of meals served was complete and up to date. Since the last inspection a nutritional input chart had been maintained for each resident. Manderley Residential Care Home DS0000064567.V355277.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to express their views and had access to a complaints procedure. Policies and procedures were in place to respond effectively to any allegations or suspicions of abuse. EVIDENCE: The complaints procedure was included in the service users guide and statement of purpose. The procedure contained the necessary information should a resident wish to raise a concern. The residents were aware of the procedure and said they would speak to the manager in the event of a problem. Further to this, the residents said they felt able to voice their views and opinions of life in the home. The registered provider had received one complaint since the last inspection. The complaint had been recorded along with the details of the investigation and outcome. A copy of “No Secrets in Lancashire” (The joint strategy for the protection of vulnerable adults) was available along with a policy document on “Elder Abuse”. At the time of the inspection, the procedure to be followed in the event of any allegations of abuse or harm was not available. However, the procedure was seen at a previous inspection and the area manager confirmed it had been found in the days following the visit. Staff had access to a whistle blowing procedure and had received training on the Protection of Vulnerable Adults Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 17 (POVA) and dealing with challenging behaviour. The requirement to carry out a check of the POVA list in relation to all new members of staff was included in the recruitment and protection procedure and various policies and procedures were in place to protect the financial arrangements of the residents. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were provided with a clean, pleasant and comfortable environment. EVIDENCE: Manderley is a mature property set in its own grounds. The home is within a mile of eth town centre. Accommodation is provided in 11 single bedrooms and 2 double bedrooms, none of the bedrooms have an ensuite facility. There were screens available for use in the shared rooms. The first floor was accessed by a stair lift. Communal space was provided in two lounges and a dining room. The residents were able to choose where they preferred to sit and could move round the home as they wished. The residents had access to the gardens, which included seating areas. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 19 It was evident from a tour of the premises that the residents had personalised their rooms with their own belongings and decoration was good throughout. The residents spoken to said they liked their bedrooms, which they said were comfortable and warm. However, one person was concerned about the lack of storage in his room. The manager reported that a new bed with storage drawers was being purchased for the resident, in order to address this issue. The bedrooms were checked each month by a nominated person and arrangements were in place to carry out any maintenance or general repairs. Since the last inspection, the lounges, dining room and hall, stairs and landing had been redecorated. The residents had been consulted about the colour schemes and were pleased with the results. There were a sufficient number of bathrooms and toilets and a new specialist bath had been installed. However, it was noted that the toilet door on the first floor would not stay closed when pulled to; this had the potential to compromise the residents’ privacy, especially those residents who were unable to operate the lock. The residents had been provided with appropriate aids and adaptations to assist their independence skills. These included grab rails; handrails raised toilet, ramps for wheelchairs and hoists. Since the last inspection, a hoist had been purchased for use on the first floor. The home was clean and odour free at the time of the visit. The residents spoken to said a good level of hygiene was maintained at all times. There was a separate laundry area in the basement, which had sufficient and appropriate equipment to meet the laundry needs of the number of residents accommodated. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff received appropriate training commensurate with their role and new staff were vetted before commencing employment in the home. EVIDENCE: A staff rota was completed in advance, which clearly demonstrated which staff were working on a particular day. All staff carrying out care duties were aged at least 18 and all staff left in charge of a building were aged at least 21. A recruitment and selection procedure was available, which covered all current regulatory requirements. The files of three members of staff, who had commenced work in the home since the last inspection, were examined. One person had since left employment with the home. From documentation seen in personal files it was evident all three people had completed an application form, provided a full history of employment and attended the home for an interview. Appropriate Police checks and references were obtained prior to the staff commencing work in the home. However, it was noted that a risk assessment had not been carried out following receipt of one particular check. Arrangements were in place for the induction of the new staff. At the time of the inspection the staff had completed an in house induction, however, there was no evidence to indicate they had commenced a “Skills for Care” induction. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 21 Each member of staff had a training and development plan and there was an overall staff training plan. The staff had completed a wide range of training courses including equality and discrimination, POVA, infection control, managing challenging behaviour and medication awareness. All staff spoken to said the training was useful and informative and they welcomed the opportunity to update their knowledge and skills. At the time of the inspection, six staff had completed NVQ 2 or above, this equated to 60 of the staff team. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents lacked the benefit of a registered manager and the quality assurance systems were not fully established. Appropriate systems were in place to protect the health and safety of the residents. EVIDENCE: Since the last key inspection, there had been a change of manager. The current manager commenced working in the home in September 2007. The manager had seven years management experience and 21 years working in various residential settings. The manager had also completed NVQ level 4 in Care and Management as well as a Certificate in Management. At the time of the visit, the manager had not submitted an application for registration. The home has been without a registered manager since October 2005. Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 23 Staff were given the opportunity to attend regular staff meetings and were able to contribute to the agenda. Minutes taken at the meetings were seen during the inspection. The manager was in the process of devising a programme of staff supervision. There were no records seen of staff supervisions. The service had been awarded an Investors in People Award in 2007. Satisfaction questionnaires had been distributed in June 2007, however, the results of the survey were not available. Residents’ meetings had been held on a regular basis and from the minutes seen the residents had been consulted about all aspects of life in the home. The current management team were developing the quality assurance processes and intended to carry out a survey with the residents and their relatives in the near future. Whilst a detailed improvement plan had been submitted to the Commission following the last inspection, an overall development plan based on the outcomes of the quality assurance processes was not seen. 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 policies and procedures available, which included the safe storage of hazardous substances. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Training certificates were seen on a sample of staff files. Documentation was seen during the inspection, which confirmed the gas, fire and electrical safety systems had been serviced. Documentation had also been submitted to the Commission to confirm all remedial work on the electrical work on the electrical systems had been completed. Appropriate arrangements were in place for recording accidents and incidents in the home. Manderley Residential Care Home DS0000064567.V355277.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 2 3 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement The residents must be involved in the development and review of their care plans, to ensure they have an input into the delivery of their personal care. Risk assessments must include management strategies, in order for staff to be aware of how to reduce or eliminate any identified risks. The risk assessments must be kept under review and updated in line with changing needs. Following thorough consultation with the residents a programme of activities must be provided on a regular basis. This is to ensure the residents have the opportunity to develop their skills and pursue a variety meaningful activities inside and outside the home. The residents must be consulted and the food provided must be monitored, to ensure the residents receive a variety of wholesome meals in accordance with their individual preferences. Arrangements must be made to DS0000064567.V355277.R01.S.doc Timescale for action 15/02/08 2. OP8 13 (4) (c) 15/01/08 3. OP12 16 (2) (n) 15/02/08 4. OP15 16 (2) (i) 01/02/08 5. OP21 12 (4) (a) 01/02/08 Page 26 Manderley Residential Care Home Version 5.2 ensure the toilet door remains closed. This is to ensure the residents’ right to privacy is protected. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The service users guide should be presented in a format, which is suitable for the needs of the residents. This is to ensure the guide is meaningful to the residents. The residents should be involved wherever possible in the review of their care needs. Evidence of consultation should be demonstrated on the personal files. This is to ensure the residents have input into the delivery of their care. A consistent record should be maintained of the residents’ weights, to ensure any significant fluctuations are promptly identified and medical advice is sought as necessary. The protection of vulnerable adults procedure should be readily available at all times, to ensure staff respond appropriately in the event of any allegation of abuse. A risk assessment should be carried out following receipt of any adverse recruitment checks, to ensure the residents are fully protected. An annual development plan should be developed based on the outcomes of the quality assurance system. This is to ensure the service is developed in line with the best interests of the residents. A programme of staff supervision should be devised to ensure the staff receive supervision at least six times a year. This offers the opportunity for staff to discuss their work performance and identify any future training needs. 2 OP3 3. OP8 4 5 6 OP18 OP29 OP33 7 OP36 Manderley Residential Care Home DS0000064567.V355277.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Manderley Residential Care Home DS0000064567.V355277.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. 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