Inspection on 12/12/05 for Manley Court Nursing Home

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Manley Court Nursing Home 16/05/08

Manley Court Nursing Home 17/10/07

Manley Court Nursing Home 07/06/06

Manley Court Nursing Home 21/06/05

Manley Court Nursing Home 26/10/04

Manley Court Nursing Home 15/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Manley Court Nursing Home Manley Court John Williams` Close, Off Cold Blow Lane New Cross London SE14 5XA Lead Inspector Ornella Cavuoto Unannounced Inspection 10:00 12 &13 December 2005 th th 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 Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manley Court Nursing Home Address Manley Court John Williams` Close, Off Cold Blow Lane New Cross London SE14 5XA 020 7635 4600 020 7639 9433 phil.moon@manleycourt.ansplc.co.uk 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) ANS Homes Limited Care Home 85 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0), Physical disability (0), Physical disability over 65 years of age (0), Terminally ill (0), Terminally ill over 65 years of age (0) Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 49 older persons, of whom up to 6 may be terminally ill, and up to 14 may be 40 years old and above with chronic illness 36 persons with dementia, over the age of 55 years Date of last inspection Brief Description of the Service: Manley Court is a purpose built home providing care and nursing for up to 85 service users, of whom 36 may have dementia, 49 may be frail older people, of whom 6 may be in receipt of palliative care and 14 may be aged over 40 yrs of age and have chronic illness. The home is owned by the private, nationwide company Associated Nursing Services but has recently been taken over by BUPA Care Services. It is situated in a residential area of New Cross Gate. The nearest shops and railway station are ten minutes walk away. The nearest bus stop is several minutes walk away. The home was opened in 1996 and is on two floors. It is divided into five units of which two provide nursing care. There are two units for people with dementia and a small unit with rooms for people in need of palliative care nursing. All the bedrooms are single with en-suite facilities. There is a passenger lift. The home has two gardens at the rear that are accessible and secure. There is car parking at the front of the building. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out over two days. The inspection involved speaking to nine service users, five relatives and four staff members including nurses and care staff. The registered manager was on annual leave at the time of the inspection but the Head of Nursing who is also the Deputy Manager was available for the duration of the inspection. Other methods used included a tour of the premises and inspection of records. What the service does well: The majority of the service users and relatives spoken to were very positive about the home and the standard of care they receive and also about the staff. One relative spoken to commented, “The improvement in her care since she has been here has been wonderful.” whilst another relative said, “I have been able to relax since she has been here.” And referring to staff “They are respectful and good with her. They have got to know her and me. They always make me feel welcome and come in to talk to me and keep me informed of everything” Service users spoken to with regards to staff stated “It does not matter what I need they will get it for me.” Another said “Staff are respectful and I feel well cared for since I have been at the home”. The home offers comprehensive support to service users using a variety of specialised services such as psychiatrists, nutrition specialists and speech therapists ensuring all presenting needs of service users are met. It is apparent from the comments from relatives that the home encourages a lot of contact and involvement from visitors who are able to visit at all times. Generally service users are supported to maintain links with the local community and where appropriate are given a lot of freedom and independence with visits and stays with family being arranged. Also, some service users attend local day centres and where required culturally specific day centres are accessed on behalf of service users ensuring service users individual needs are met. The food offered by the home is of a good standard; the menu offers a lot of choice and service user preferences are catered for. Feedback from service users about the food was largely positive. Both the Registered Manager and the Head of Nursing have received training to enable them to deliver courses on adult abuse ensuring staff are trained and have a good level of awareness in this area. Furthermore, the overall training needs of staff are well met with staff being given the opportunity to access relevant training to meet the specific needs of service users as well as mandatory training. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The home must ensure that all service users receive a contract outlining the terms and conditions of their stay within the home. Service users should sign this and a copy kept on their individual files. The home must ensure that all service users and/or relatives or a representative where appropriate are involved in the drawing up and reviewing of care plans. Also, risk assessments should be signed and reviewed regularly. The home must ensure that all records of assessments and care that is provided are completed thoroughly and accurately including turning charts for pressure area care to ensure that all healthcare of service users are being fully met. The home must ensure that service users preferences around personal care are obtained and where preferences are stated that staff ensures these are up held. The home must ensure that all policies and procedures in respect to administration and handling of medication are adhered to at all times by staff. The staff must be encouraged to sensitively consult with all service users around their personal wishes around death and dying and that this is recorded in their care plans. The home must ensure that staff maintains service users rights to be offered an alternative from the menu. The home must ensure that the home is well maintained with repairs being carried out promptly and renewal of items being purchased. The home must ensure that all areas of the home are kept free from offensive odours. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 7 The home must ensure that all appropriate checks and documents required by regulation have been obtained prior to staff being allowed to commence work within the home. The home needs to develop a formal quality assurance system that involves consultation with service users, relatives and other stakeholders involved in the service and the results of which are drawn together and feedback given to those involved in the form of a report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 &5 Standard 6 is not applicable. Service users have the information they need to make an informed choice about where they live. Service users have not received a contract/statement of terms and conditions with the home that is signed by them. Service users know that the home they enter will meet their needs. Generally, the home ensures that prospective service users and their relatives have an opportunity to visit the home prior to making a decision to move in. EVIDENCE: The home has been issued with a Statement of Purpose and Service User Guide that has been produced by BUPA Care services. These are comprehensive and include all information required by regulation. Similarly the home has been provided with a new contract by BUPA Care Services. Subject to a previous requirement, this needs to be signed by all service users to ensure their rights have been protected and a copy retained on individual files. However, as yet these have not been issued to service users. Therefore, this is to be restated as a requirement in this report. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 10 It was evident that the home is able to meet the needs of all service users living within the home. Specialised services are offered. The home has strong links with the local community mental health team and a consultant psychiatrist regularly visits the home to check and monitor the needs of service users particularly those with dementia. The home also liaises closely with the Care Homes Support Team, which includes an Older Persons nurse specialist. They also use nutritional specialists and speech therapists as required. The home was also able to demonstrate that staff individually and collectively does have skills and experience to meet the needs of service users and deliver the services the home offers to provide. It was reported that although it is not always possible for service users to visit the home prior to admission due to being in hospital or having memory impairment the home ensures that a relative, friend or a representative does come to look around the home on service users’ behalf. Relatives who were spoken to during the inspection confirmed they had an opportunity to visit the home and speak to staff. All new service users stay for a six-week trial period. Reviews are then undertaken with the social worker and if there are no problems the placements are made permanent. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 &11 Care plans are generally comprehensive and although care plans are reviewed regularly they do not always evidence the involvement of service users and /or relatives or representatives in the care planning process. Recording of care provided does not evidence that service users health care needs are being fully met and risk assessments are not being reviewed regularly. The service has robust policies and procedures on medication but these are not always being adhered to and therefore are not fully protecting service users. Service users feel they are treated with respect and their right to privacy is upheld. Not all service users have been consulted about wishes around the issue of death and dying. EVIDENCE: A sample of service user plans was inspected. Care plans are aimed at being drawn up following the completion of a number of assessments including incontinence, pain, nutrition and communication amongst others. Although care plans were generally very clear and comprehensive it was noted that for a number of service users not all the assessments had been completed and some were only partially completed. This could potentially result in service users Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 12 needs being overlooked. Although, it was evident that certain assessments may not be appropriate to service users needs this should be clearly indicated rather than assessments being left uncompleted. Subject to a previous requirement that all records of assessments and also care given are completed thoroughly and accurately this is to be restated in this report. There was evidence that all care plans have been reviewed monthly. The home has developed a care plan review form, which is a summary of the care plan, and subject to a previous recommendation this has now been implemented. Changes in service users needs and circumstances are reflected in the review forms. However, subject to a previous requirement that these should be signed by the service user and/or relative to indicate their involvement in the care planning process although there has been an improvement with some forms being signed there was still a number that were unsigned. Therefore, this is to be restated as a requirement in this report. All service user plans contained a risk assessment but some had not been signed either by service users or staff. Also, many had not been reviewed. Subject to a requirement. Service user plans generally indicate that health care needs are being met with evidence of close liaison with a range of healthcare professionals including nutritional specialists, psychiatrists, tissue viability nurses, speech therapists amongst others. However, care records reflected inconsistencies. For example, for one service user where concerns had been identified around nutrition due to regular vomiting after eating and drinking despite there being a food and fluid checklist on file this had not been completed. Subject to a requirement. Furthermore, service users who had pressure sores pressure area turning charts showed that they were not being turned regularly enough. However, other care and treatment of these was properly recorded with involvement of the tissue viability nurse being evidenced, photographs being taken and wound care progress charts in place. Subject to a previous requirement that good practice in pressure area care is followed at all times although this has been partially met this is to be restated in this report. In respect to personal care the majority of service users were observed as being well dressed and well groomed. However, recording within service user plans indicated that service users preferences around having baths or showers had not always been addressed with them. Also, where a service users preference had been specified this was not being met as records indicated that service users were receiving bed baths rather than showers and baths. Subject to a requirement. The home has robust medication policies and procedures and only trained staff administer medication. Monthly audits on the medication are also carried out. A sample of Medication Administration Record (MAR) sheets were checked and inaccuracies were found including medication being administered and not signed for and medication stock not correlating with the MARS sheets. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 13 Controlled drugs were also checked and these were in order but daily checks of controlled drugs had not been carried out. Subject to requirements. A previous requirement to ensure that fridge and room temperatures are kept within the required range has been addressed. It was evident from speaking to service users that they consider that they are treated respectfully by staff and that their privacy and dignity are maintained. Service users confirmed that staff do knock before entering rooms and service users were observed being given their mail unopened. In respect to service users wishes being obtained around death and dying, these were not in place for all service users. It was reported that staff find it difficult to approach the topic with service users. Yet the importance of having these recorded within service users files was acknowledged and that staff need to be encouraged to sensitively consult service users on this issue. Subject to a recommendation. . Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 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): 13,14 &15 Service users are encouraged to maintain contact with family and friends and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a balanced diet although staff are not always ensuring service users needs are being catered for. EVIDENCE: Visits from family and friends are very much encouraged by the home to ensure that service users maintain relationships of importance to them. Relatives and service users spoken to during the inspection confirmed that they are able to visit at any time and are always made to feel welcome by staff. Also, one service user living at the home is supported to make regular visits home to see a relative and it was reported that stays with family or friends are also arranged by the home where appropriate. It is evident that service users are supported to exercise control and choice over their lives. In relation to service users being able to being in personal possessions with them a relative spoken to said “It has been made clear to me that she can bring in anything she wants in having her own things around her, they have encouraged her.” Other service rooms inspected also had items of their own furniture and other personal effects. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 15 The home provides information to service users about local advocacy schemes and has a policy on advocacy. It was also reported that service users can access personal records if they wish. Feedback from service users about the food provided by the home was largely positive. One service user commented, “ The food is presented well”. Another service user said “ The food is good “ and also that there was a choice of meals available that caters to their particular cultural needs. Inspection of the menu confirmed that there is a good variety and choice of meals. Lunchtime was observed in two separate units within the home. Overall both were relaxed and unhurried. A previous requirement that staff assisting service users to eat should be trained to do so in a sensitive and respectful manner appears to have been addressed with staff being observed providing support to service users to eat in an appropriate way. However, in respect to one service user who expressed they were not happy with their dessert the staff member serving did not offer her alternative until the inspector eventually had to intervene. Subject to a requirement. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 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): 18 Service are protected from abuse EVIDENCE: The home has robust policies and procedures on adult protection and whistle blowing. Any allegations and incidents of abuse are followed up promptly and any concerns passed onto the Commission for Social Care Inspection (CSCI). Evidence of documentation sent to CSCI regarding incidents demonstrates that these are thoroughly investigated. During the inspection a service user who suffers from memory impairment made an allegation that a staff member hit them. This was immediately and appropriately addressed with no evidence being found to substantiate the claim. Furthermore, the home is presently managing a situation in which a relative was found to be placing a service user at risk of harm by interfering with their treatment. Evidence shows that the situation has been very well managed by the home. Both the Registered Manager and the Head of Nursing are strongly committed to protect service users from abuse and they have both completed courses to provide training in adult protection at the home. There was evidence on the majority of staff files that were inspected that staff have received training in this area. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 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): 19,25 &26 Service users live in a safe environment that is generally well maintained but some repairs and renewals of items are required. Service users live in comfortable surroundings. The home is generally clean and hygienic but there is an unpleasant smell in one area of the home. EVIDENCE: The home is purpose built and offers single en suite accommodation with adequate personal and communal space. The home is divided into five separate units. There are lounges and dining areas on each unit and enclosed gardens at the rear of the premises. There are bathrooms with assisted baths and showers. Overall the home is bright and airy and decorated and furnished appropriately. It is generally well maintained. The home has undergone recent refurbishment in parts. A previous requirement made that the kitchen stairwell needed decorating has been completed although the carpet is still in need of being replaced. It was reported that this has been ordered. In addition, it was noted that there was a large crack in the wall on the stairwell by Hibiscus Unit that needs investigating, as it could potentially be a result of subsidence and Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 18 needs to be repaired. Furthermore, the carpet in the activities room was badly stained and needs to be replaced with a new one. A small kitchen on Primrose Unit that is used by carers to prepare meals and wash up is in need of refurbishment and a kitchen draw was missing which needs to be replaced. Subject to requirements. The home is well ventilated. Rooms are centrally heated; radiators have low temperature surfaces and can be individually regulated. Lighting is appropriate in service users rooms. The home also has emergency lighting that is tested regularly. Evidence was also seen that water temperatures are tested to prevent risks of Legion Ella and to prevent risks from scalding. The home was clean on the day of the inspection although unpleasant aromas were evident in one area of the home in Lavender Unit. The home has made extensive efforts to try to address this problem. It was reported that carpets have been replaced with alternative floor coverings in consultation with service users and relatives, which it was reported, has helped to alleviate the problem. In addition, the home has been taking part in a national study on Continence in Dementia which it is hoped will assist in developing more effective ways to promote continence in addition to those already used by the home. Unfortunately, the Head of Nursing was unable to give an update on the progress of the study and so this will be followed up at the next inspection. Subject to a requirement. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 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 &30 The numbers and skill mix of staff meets Service users needs. The majority of staff have either achieved the NVQ Level 2 in care or are in the process of studying for the qualification. Although the home is addressing previous requirements made in relation to the home’s recruitment practices there are still areas of practice that are not protecting service users. Staff are trained and competent to do their jobs. EVIDENCE: Staffing levels have remained unchanged since previous inspections and are as follows: on Hibiscus, Lavender and Primrose units, there is one nurse and three care assistants on morning and afternoon shifts and one nurse and one care assistant at night. On Jasmine Unit there is one nurse and four care assistants in the morning, one nurse and three care assistants in the afternoon and one nurse and two care assistants at night. The palliative care unit has one nurse and one care assistant on both daytime shifts and one nurse at night. There appeared to be sufficient staff on duty on both days that the inspection was carried out. The home also uses a bank of nurses and care assistants that are presently employed directly by the company that owned the home. It is as yet unclear whether this arrangement will continue now the home has been taken over by BUPA Care Services. Bank staff are used as back up cover for when full time staff are on holiday or off sick. It was reported that where possible the use of agency staff are not used but that recently due to a high turn over of staff and awaiting Criminal Bureau Record Checks (CRBs) for new staff to start work the home has had to use some agency staff. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 20 The home is committed to training staff although it was reported that there is a problem retaining staff at times resulting in new staff having to be recruited and supported to undertake training. At present, the home which employs 46 care assistants has 16 care staff who have achieved a NVQ Level 2 in care and 4 have completed a NVQ Level 3 whilst 18 are in the process of training for the NVQ Level 2 qualification and one is presently doing the NVQ Level 3. This means that the home has nearly achieved the required 50 of staff being trained to NVQ Level 2 by the end of 2005. Eleven staff files were checked in relation to recruitment. There have been concerns about the homes recruitment practice from the last two inspections. Subject to a previous requirement that the home must ensure that a CRB check from England and Wales is obtained for all existing staff and for all new staff recruited as opposed to being obtained from Scotland which is not acceptable under the Care Standards Act legislation this process has been undertaken. Evidence was seen that new appropriate CRB checks have been obtained for the majority of those staff working within the home. However, it was identified that three staff members were working within the home without the home having obtained a CRB check or a check being made against the POVA list. An immediate requirement was issued following the inspection that these checks need to be obtained as soon as possible. Although .it is clear that the home has made improvements in their recruitment practices with two references and appropriate identification being obtained the home must continue to ensure all necessary checks and documentation is in place prior to staff being allowed to commence work. Therefore, this requirement is to be restated in this report. There was evidence that staff are in receipt of induction and regular training in respect to mandatory training and also other training to enable them to meet the specific needs of service users. Each staff member has an individual training record and there is also a folder for mandatory training for all staff to ensure this is monitored and updated as required. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 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): 31,33,35 & 38 Service users live in a home that is run and managed by a person who is fit to be in charge, of good character and able to discharge their responsibilities fully. The home needs to ensure that a more formal quality assurance system that includes consultation with service users and other stakeholders in the service is developed. Service users financial interests are safeguarded. The health and safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager was not present at the inspection and so this standard could not be fully inspected but it is evident from previous inspections and feedback from staff that she is competent and committed to the work carried out at Manley Court in relation to service users and staff. Subject to a previous requirement Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 22 that the manager must be registered in accordance with the Care Homes Regulations this process is being undertaken. The home does carry out some self-monitoring performing its own monthly audits of care plans, medication, cleaning and an environmental audit of all service users rooms. Also, although it was reported that a customer satisfaction survey was recently carried out with service users by BUPA Care Services who have recently taken over the ownership of the home, it was thought this was completed more for the purpose of gathering information for the company rather than for service users. Subject to a previous requirement that the home must ensure that an annual survey is conducted of the views of service users, representatives and other stakeholders there was no evidence available to indicate this has been addressed. Therefore, this is to be restated as a requirement in this report. Also, there was no evidence available that monthly provider reports have been completed of which copies must be sent to CSCI. Subject to a previous requirement this is to be restated as a requirement in this report. In respect to service user finances, the home is presently in the process of transferring the management of these to the system that is used by BUPA Care Services. However, it was the established system presently still in place that was inspected. One of the administrators went through how service users monies are managed by the home. The home manages the personal allowance for the many of the service users, which are paid into a non-interest bearing account. Detailed records of payments and withdrawals relating to each individual with funds in the account are maintained and balances are given to service users after each transaction that also acts as a receipt. The home also produces a statement every 28 days to ensure that all monies reconcile with transactions carried out over the month. It was also reported that if money builds up for service users this is transferred into their own Savings Accounts for those that have them. Head Office carries out an internal audit on service users finances and spot checks are also carried out. Although it is evident that service users finances are well managed by the home the care standards do state that service users personal allowance should not be pooled and the issue of the home ensuring service users have individual bank accounts has been raised at previous inspections. As the home is introducing a new system to manage service users finances a requirement is not to be stated in this report but this will be looked at in further detail at the next inspection. The home has comprehensive policies and procedures in place with regards to all aspects of health and safety. Risk assessments are in place and health and safety are carried out monthly. All service have a moving and handling assessment and staff are fully inducted and trained in safe manual handling techniques and other aspects of health and safety including fire procedures and drills which are carried out regularly. A previous requirement that the time of the drills need to be recorded to ensure that these were being carried out at different times has been met. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 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 ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score 3 2 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 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 OP2 Regulation 5(1)(c) Requirement The registered provider must ensure that on moving in to the home, each service user is provided with a statement of terms and conditions, that includes all of the information listed under Standard 2.2 of the National Minimum Standards and it is signed by the provider and the service user or their representative. (Previous timescale of 31/01/05 and 30/09/05 not met) The registered person must ensure that all service users and or a relative or a representative where appropriate are involved in the drawing up and reviewing of care plans and that this is indicated by a signature being obtained. (Previous timescale of 30/09/05 not met) The registered person must ensure that staff signs all risk assessments and service users and these are regularly reviewed. The registered person must ensure that service users DS0000006997.V269492.R01.S.doc Timescale for action 30/04/06 2. OP7 15(1)&(2) 30/06/06 3. OP7 13(4)(b)& (c) 30/06/06 4. OP7 15(2)(c) 30/06/06 Manley Court Nursing Home Version 5.0 Page 25 5. OP8 12(1)(a)& 17(1)(a) 6. OP8 12(1)&(2) 7. OP9 13(2) 8. 9. OP15 OP19 12(5)(b)& 16(2)(i) 23(2)(a) (b)(c)&(d) preferences are obtained in respect to how they would like their personal care carried out and that staff ensure their personal choices are upheld. The registered provider must ensure that all records of assessments and care given are completed thoroughly and accurately as a measure to ensure health care needs are being fully met. These should include dates and staff signatures. (Previous timescale of 30/06/05 and 30/09/05 not met). The registered provider must ensure that good practice in pressure area care is followed at all times. (Previous timescale of 31/05/05 & 30/09/05 not met) The registered person must ensure that the systems in place for recording and monitoring the administration of medication are used consistently and effectively specifically staff sign the medication administration records for all medication administered, that controlled drugs are checked daily and in respect to handling medication that stocks of tablets correspond to that amount recorded on the MARS (Medication Administration Record) sheets. The registered person must ensure that staff always offers service users a choice of food. The registered person must ensure that repairs are carried out and renewals of items are purchased. This specifically includes: a) The carpet on the kitchen stairwell being replaced. b) The crack on the stairwell by Hibiscus unit being looked into DS0000006997.V269492.R01.S.doc 30/06/06 30/06/06 30/06/06 30/06/06 31/08/06 Manley Court Nursing Home Version 5.0 Page 26 10. OP26 16(2)(k) 11. OP29 19(1) 12. OP33 26 13. OP33 24 and repaired. c) The carpet in the activities room being replaced. d) The small kitchen on Primrose unit being refurbished and the kitchen draw being replaced. (Previous requirement timescale not expired) The registered person must ensure that all areas of the home are kept free from offensive odours. The registered person must ensure that any new staff to commence employment in the care home are not allowed to do so before all necessary documents and checks have been obtained specifically two satisfactory written references, a satisfactory disclosure from CRB England and Wales at the appropriate level has been received and a check has been made against the POVA list. (An immediate requirement issued and previous timescale of 31/10/05 not met). The registered provider must ensure that copies of reports of visits conducted in accordance with this regulation are sent to CSCI (Southwark office)(Previous timescale of 30/09/05 not met) The registered provider must ensure that an annual survey is conducted of the views of service users, representatives and other stakeholders to ensure that the service is developed in accordance with their views. (Previous timescale of 31/10/05 not met) 30/06/06 31/03/06 30/06/06 30/06/06 Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 27 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 OP11 Good Practice Recommendations The registered person should encourage staff to sensitively consult with all service users around their personal wishes for death and dying and these are recorded in the service user plan. Manley Court Nursing Home DS0000006997.V269492.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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