Inspection on 17/10/07 for Manley Court Nursing Home

This inspection was carried out on 17th October 2007.

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

The inspector 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 07/06/06

Manley Court Nursing Home 12/12/05

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 Lynne Field & Mary Magee Unannounced Inspection 17th & 24th October 2007 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 Manley Court Nursing Home DS0000006997.V340627.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. Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 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.V340627.R01.S.doc Version 5.2 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 18th December 2006 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 a chronic illness. The private, nationwide company BUPA Care Services who took it over from Associated Nursing Services (ANS) in the past year owns the home. 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. The home has a brochure and a resident’s guide that is made accessible to all prospective service users. Copies of CSCI reports are kept in the reception area and a copy is given to service users, relatives or a representative on request. The home’s fees range from £635 - £917 monthly. Additional charges are made for hairdressing, toiletries, newspapers, outings, taxis and clothing. This information was provided to CSCI June 2007. Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted by two inspectors and took place over two days on 17th and 24th October 2007. The inspection involved speaking twenty residents, seven relatives, the staff on duty and the manager. Care managers were spoken to on the telephone before the inspection. Six relatives, twelve residents and seven staff were returned to the inspector. The manager returned a standard form, the Annual Quality Assurance Assessment (AQAA), to CSCI and this was taken into consideration. The inspection also involved the case tracking of nine people’s care, the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. What the service does well: The home continues to offer comprehensive support to residents using a variety of specialised services through a range of professionals such as psychiatrists, nutrition specialists and speech therapists ensuring all the needs of residents are met. Residents care plans are reviewed on a regular basis and generally health care needs are well met. Staff ensure the privacy and dignity of residents is maintained and they are supported to exercise choice and control over their own lives as much as possible. The home has a good range of activities including regular exercise to keep residents stimulated and to ensure they are able to socially interact with others in and away from the home. Residents are encouraged to maintain contact with relatives and friends and encourage them to keep in contact where possible. The home provides a varied menu that offers a choice of meals and specific preferences and cultural needs are catered for. The home ensures residents are well protected with an effective complaints policy and procedure in place that is accessible to residents and also by ensuring that all staff are trained and informed about adult abuse. They have effective policies and procedures in place around adult protection and follow policies and procedures when the need arises. The majority of the staff are trained to National Vocational Qualification (NVQ) Level 2 in care and others are being supported by the home to undertake the qualification. Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 6 There is a comprehensive induction programme in place for new staff and a comprehensive training program for both trained nurses and care staff. What has improved since the last inspection? What they could do better: 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. Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 7 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.V340627.R01.S.doc Version 5.2 Page 8 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): 1.2,3,4,5 Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service users’ guide are good at providing prospective residents with details of the service the home provides. Assessment information set out clearly the needs of the residents using the service. Staff know residents well and they use this knowledge as well as the assessment information to work with people to best need their needs. EVIDENCE: The inspector was shown the statement of purpose and the resident’s guide, which includes the complaints procedure in the resident’s guide. The manager Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 9 told the inspector, that these are regularly checked and updated to reflect the changes in the home and the organisation that runs the service and would be up dated when the new manager came into post at the beginning of November 2007. The acting manager told the inspector a copy of Lewisham Social Services care assessment would be faxed to the home and where possible the prospective resident and /or their family would visit the home to see if it was suitable. The manager would visit the resident and a full needs assessment would be completed to ensure the home could meet the prospective residents needs before a place in the home was offered. Two relatives who spoke to the inspector confirmed this. One relative said they had heard good reports about the home from another relative who they knew and came to view it. Case tracking was used to evaluate the care arrangements for four residents on the ground floor and five residents on the first floor. One is on the palliative care unit. Two of the assessments viewed were for two recently admitted residents. The information recorded in both assessments show how consideration is given to all areas of both health and social care needs. Copies of care management assessments are held too for both residents. This assists staff get a full picture of why referrals were made for nursing care. The inspector was shown a copy of the contracts that are provided to residents that are self-funding. BUPA has recently developed a contract format for residents funded by local authorities or care trusts, not yet in operation for residents at the home but is in the process of being rolled out. Intermediate care is not provided and therefore standard six was not assessed. Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning has improved with systems in place to ensure that this improvement continues. Residents find that healthcare is promoted and that consultations are sought as necessary with professionals. Residents feel they are treated with respect and their right to privacy is upheld. The home has robust policies and procedures on medication but these are not always being adhered to by staff and therefore are not fully protecting residents. EVIDENCE: Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 11 The home is using a system called QUEST, which is an assessment tool with mandatory fields in the principles of care planning used in all BUPA homes. Individual care plans are developed from the individual needs assessment to make sure the health and personal care needs of residents are met. On admission all residents are weighed and within six hours of admission a range of risk assessments including Waterlow scores are completed. Care plans for nine residents were examined. The care plans are clear and set out all the support, assistance and needs of each resident. BUPA assessments for activities of daily living include standard statements, which have a number rating. Included within this documentation are mandatory care plans for nutrition, falls and manual handling. In those files inspected these were completed. Supporting records for two resident include fluid intake charts, these were fully completed with adequate intake recorded. One resident is currently having difficulty with intake of fluid and on occasions the intake is poor. A referral was made to the multidisciplinary team to discuss future plans. Advocacy contact had also been made due to cognitive functioning. One of the newly admitted residents has pressure sores on admission. So far these are dressed in accordance with recommendations sent by hospital team. A pressure-relieving mattress was supplied on the bed prior to admission. Staff had concerns on the wound management and the tissue viability nurse was contacted for further advice. The inspector observed that in general care plans contain good information in the intervention section, this provides staff with a good foundation and guidance to give the care required. The care plans are relevant to current areas of identified need and include supporting documentation such as risk assessments. Issues such as sleeping and end of life were covered in the documentation. Sensitivity and tact is used when discussing delicate issues such as end of life management. Staff spoke of a resident recently admitted, said, “ this has not been discussed yet as the resident is not ready for it”, this was also recorded in end of life care plan. There were records of pain management for a resident requiring palliative care. It was identified that for one resident the general condition is poor, the waterlow scores are in the very high-risk band. More frequent monitoring takes place to respond to this. Risk management strategies are agreed following risk assessments. Attention is given to assessing the need for use of cot sides and agreements are signed to indicate consent by either residents or relatives/ representatives. One resident said they did not need cot sides and this was recorded and signed by the resident and staff. Continence assessments are completed for residents on admission and regularly reviewed thereafter. Manual handling assessments, weight records and pressure sore risks are kept updated and demonstrate that that these are kept under review. However attention is needed as to how staff Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 12 make provision for the prevention and control of infection. A recently admitted resident had recorded on the needs assessment that MRSA was present on a wound. The procedures in place did not make adequate provision for this. A requirement is stated. See Standard 26. There are lifestyles profiles included which provided valuable information about the residents past life, personal preferences. Daily records maintained provide evidence of the care delivered both during the day and night time. From inspecting the records the inspector could see health care is promoted. The records relating to health care indicated input from the GP and the multidisciplinary team and records are kept of the results of daily blood sugar tests. There were reports on the outcomes of CPA meetings. There are indications of positive outcomes for residents. The inspector found that for two of the residents progress has been made since moving to the home. The residents and their relatives, who spoke to the inspector, spoke positively of their experiences. The practice of administering medications was observed during the morning period. The practice was safe. In the front of the medication file was the NMC guidelines on medications and the BUPA policy. A staff signatures list was also available. On the Medication Administration Records (MAR) charts, there were clear photographs of the residents and their allergies recorded. The charts were completed and no gaps evident. Records of medications received in to the home were in place. The medication that had been disposed of, had two signatures confirming their disposal. One resident on the palliative care unit was kept comfortable by medication that is administered as required to control any pain. The inspector found some discrepancies in the frequency of administration to the prescribed. A requirement is stated. As part of this inspection, the pharmacy inspector will conduct a full medication inspection in December 2007 and will issues a separate report on her findings. Manley Court Nursing Home DS0000006997.V340627.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to maintain contact with family and friends. Residents are generally supported to exercise control and choice over their lives. Residents receive a varied and balanced diet but residents who need assistance are not always being provided this in an appropriate manner. EVIDENCE: The inspectors noted visitors coming and going throughout the day without restriction. Seven relatives were spoken to during the course of the inspection and six relatives responded to the survey sent out by the inspector. They spoke positively about the care given to residents. One man said, “I come here daily, I see the good work done by staff, it is a pleasant and friendly home to come to”. One relative said they came to look at the home on the recommendation of another residents’ relative and they were pleased with the home. Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 14 The home has an excellent activities room. One resident took the inspector to see it. They said they loved going there and enjoyed all the activities put on by the activities staff. Each resident has an activities folder with a written record of their interests and what they have attended. At the present time there is only one activities coordinator who was facilitating various activity sessions. The acting manager told the inspector they planned to advertise for another activities coordinator at some point in the near future. The inspector noted a number of activities had been planned and information about these were on the notice board advertising them. Staff were seen encouraging residents to take part in a number of these activities. Staff were also seen engaging with residents who were unable to leave their rooms or did not want to join the larger group, in one to one sessions, such as reading the newspaper to them or chatting. Two residents told the inspector they attended outside activities and they had transport arranged to take them there. The nutritional needs of residents are regularly monitored from time of admission. Those residents at risk due to poor nutrition are identified and their conditions monitored closely. Appropriate action is taken as required. This was evident from the records held for a resident recently admitted. Appropriate referrals were made to relevant health professionals to seek advice on how to promote the resident’s health further. Food supplements are supplied to those requiring food intake. The inspector joined the residents for their lunch on both days of the inspection and observed the residents enjoying their meals. Staff were seen assisting and supporting residents to eat and although this was done in a sensitive way it was not an appropriate or good practice. One member of staff was sitting between two residents assisting them to eat at the same time. The inspector spoke to staff about this and was told this was because there was not enough staff on duty to do this without residents waiting to eat their meal. This is the subject of a requirement. The inspector discussed having protected meal times with the acting manager, where no medication is dispensed during meal times and all available staff assists in serving meals and support residents who need help to eat. A number of residents and their relatives spoke positively of meals served, “ The food is generally good and very tasty” were comments received. Comments in the surveys returned to the inspector were generally positive but one relative said when their relative first came they thought the dinners were good but lately they were disappointed some things are uneatable and a comment about “get more spoons, and wash them before putting them from dinner to sweet”. The inspector noted either the cook or the domestic supervisor came around after lunch to see what residents thought about the meal. The supervisor told the inspector the home has a varied menu. They use what is called the “BUPA Menu Master” that helps them to ensure the menu meets the nutritional needs Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 15 of the residents and from this choose a menu that the residents like and meets their cultural tastes. Manley Court Nursing Home DS0000006997.V340627.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Records of complaints investigations indicate they are taken seriously and are acted upon. Residents are protected from abuse. EVIDENCE: The inspector was told the company has a clearly defined complaints policy with agreed timescales for managing complaints. All residents are issued with an information pack that is placed in their rooms. This includes a copy of the home’s complaint policy and procedure and information about advocacy services. The information that accompanies the policy is prominently displayed in the home. The policy includes a three-tier framework including the home, the regional management team and the national Quality and Compliance department. BUPA Care Homes has appointed a Director of Quality and Compliance and has developed a national Quality and Compliance team of experts. BUPA Care Homes has robust policies for dealing with allegations of abuse or neglect. Staff cannot only raise concern within the home they have access to senior staff outside the home. There are well-documented procedures for Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 17 reporting under POVA should the need arise. The manager sends reports of all complaints received by the home to CSCI and liaises with the appropriate professionals, which demonstrate that detailed investigations are always conducted and appropriate action is taken. In the last year the home has had thirty-five complaints, fourteen of which have been up held. All complaints were resolved within 28 days. In respect to adult protection the home has a robust policy and procedure. The whistle blowing policy is included in the staff handbook as well as an employee guide regarding the Protection of Vulnerable Adults (POVA) list to which referrals of staff implicated in abuse of residents are made to prevent them from continuing to work with vulnerable adults. Employee responsibilities to report abuse are also addressed in the handbook. The inspector saw records of complaints and their outcomes. There were five safe guarding adults investigations and from that two safeguarding adults referrals made and one referral to POVA. The inspector was told adult protection training was part of the staff induction training and they hoped to liaise with the local boroughs to come in and help with POVA awareness courses in the near future. Manley Court Nursing Home DS0000006997.V340627.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): 19,20,21,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe environment that is generally well maintained but shabby and some repairs and renewals still need to be carried out. Infection control needs to be more robust. 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 is a lounge and dining area on each unit that the inspector found cold, bare and uninviting. The dining tables were not attractively set for meals and there appeared to be a lack of cutlery. There are enclosed gardens at the rear of the premises. Resident’s bedrooms have been personalised with pictures, photos and small items of furniture, but some of Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 19 the homes furniture needs to be replaced. The inspector noted some curtains had been replaced. At a previous inspection in 2006 it was noted some of the home had been refurbished but there is still a number of areas and items of furniture need to be brought up to standard. Overall the home is shabby in appearance. The acting manager told the inspector BUPA had allocated money to buy identified pieces of furniture and redecorate areas of the home. He they are waiting for some furniture that is on order. A refurbishments programme is needed to address these. See requirements. The home was generally clean and hygienic when the inspection took place. But there were unpleasant smells noted on different units of the home. The carpets were cleaned during the inspection, which improved the smell. The home has robust policies and procedures around infection control and staff receive training around infection control as part of their induction. During the tour of the building the inspector noted that one residents en-suite was being used to store their wheelchair, pads and other equipment, which was blocking staffs access to the wash hand basin making it difficult for staff or visitors to wash their hands or use the toilet. Another main bathroom was being used to store hoists. As previously stated, attention is needed to how staff make provision for the prevention and control of infection. A recently admitted resident had recorded on the needs assessment that MRSA was present on a wound. The procedures in place did not make adequate provision for this. A new requirement has been made. Manley Court Nursing Home DS0000006997.V340627.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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new organisation has robust recruitment procedures to protect and keep the residents safe. Staff files need to be audited and any shortfalls needs to be addressed. Staff are trained and competent to do their jobs but supervision must be reinstated to support staff in their professional and personal development. EVIDENCE: The inspector viewed ten staff files. All staff recruited in the past twelve months have been vetted fully before they commence employment. Enhanced disclosures with POVA checks, previous employment records and references were available for three new staff. Three of the staff are registered nurses. The majority of staff have worked at the home for some time. Gaps were seen in employment history. Shortfalls were found in the numbers of references present for one care worker, current immigration status was absent. A CRB with Enhanced disclosure was absent for another member of staff. PIN numbers were recorded for nursing staff. It is good practice to up date CRBs every three years if any staff have CRBs over three years old. There was no evidence that one nurse had done the adaptation program or completed it Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 21 satisfactorily. The staff files need to be audited and any shortfalls addressed. A requirement is stated. Staffing levels were found to be appropriate to the needs and number of residents. The acting manager told the inspector the qualified nurses had been issued with a “Qualified Nurse Learning Portfolio” that is given to all BUPA trained staff. This incorporates BUPA induction, ongoing training records and supervision records. The inspector interviewed three staff from the ground floor and three staff from the two units on the first floor. Four staff were care workers and two were qualified nurses. All staff were positive about the home. Staff told the inspector that they had received training in the mandatory topics and had regular updates in these. One nurse has worked at the home for many years and has continued their professional development. The inspector received seven anonymous responses from the staff survey. Staff said they felt supported, had training and are kept informed. All but one said they felt they needed more staff and training. The inspector was told each head of department was responsible for the supervision of their staff team. Staff records inspected revealed staff supervision was still spasmodic. This requirement has been reinstated. Manley Court Nursing Home DS0000006997.V340627.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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a home that is well run and well and the best interests of the residents are promoted. Not all staff receives regular supervision. Working practices and associated records ensure that the resident’s finances and health and safety are safe guarded. EVIDENCE: Since the previous inspection in December 2006, home has experienced a change of management. There has been no registered manager since February Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 23 2007 and shortly after that the deputy manager left too. The organisation appointed an acting manager in the interim but the management arrangements have not given the home the consistency needed. The manager has had the sole responsibility for management without the support of a deputy manager. A new manager is due to take up post in November 2007. The inspector was told 30 relatives attended the relatives meeting held at the end of July 2007 and were able to voice their opinion about the home at the meeting. Relatives told the inspector they felt they could speak to the manager about any concerns they had and they would be listened to. Residents and families, both in the surveys returned and when the inspector spoke to them, said they had confidence in the management. The organisation has appointed a Director of Quality and Compliance and has developed a national Quality and Compliance team of experts and the organisation conducts regular regulation 26 visits, which are recorded. Staff said they felt supported by the homes immediate management but would like more from the organisation, such as free lunches and more money for working weekends. The inspector spoke to the administrator who has responsibility for administrating the resident’s money and helps the residents administer their finances. To protect the resident the home will only manage their money if they sign the Financial Agreement. The administrator went through the system with the inspector and explained how it was administered. Records are kept on the homes IT system and four residents finances were checked and correct. Full details of the system used by the home have not been disclosed in this report for security reasons. As stated above the inspector spoke to the maintenance man who has the responsibility for carrying out many of the health and safety checks. The home has robust policies and procedures around health and safety. The inspector was shown the records relating to health and safety measures and servicing of the equipment and these were correct and up to date. Fire safety records evidenced that fire alarm call points are carried out weekly but regular fire drills had not taken place at different times to ensure all staff are familiar with the process. The acting manager said he would do this immediately. Manley Court Nursing Home DS0000006997.V340627.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 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X X 3 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 3 X 3 X X 3 Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP10 Regulation Reg13(2) Requirement The registered person must ensure that medication is administered in accordance with prescriber’s instructions. The registered person must ensure that staff are given proper instruction about how to assist residents to eat in an appropriate and sensitive manner. The Registered Person must ensure that renewals of items are purchased and the refurbishment program continues. The registered person must ensure that adequate arrangements are in place to prevent and control the spread of infection. The registered person must ensure that an audit is completed of staff files to identify any shortfalls in recruitment. Only staff that are fully vetted must be employed. The Registered Manager must ensure that all staff receive at least 6 supervision sessions DS0000006997.V340627.R01.S.doc Timescale for action 10/12/07 2 OP15 12(4)(a) 10/12/07 3 OP19 23(2) (b)&(c) 31/03/08 4 OP26 13(3) 10/12/07 5 OP29 19 (1) (2) (3) (4) 10/12/07 6 OP36 18 (2) 10/12/07 Manley Court Nursing Home Version 5.2 Page 26 annually. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP15 OP12 OP12 Good Practice Recommendations The registered person should consider introducing protected meal times. The Registered Manager should ensure that reminiscence sessions are held particularly to support those residents with Dementia. The Registered Manager should ensure that the activities co-ordinators spend regular time doing appropriate activities with those residents that are more bed bound. Manley Court Nursing Home DS0000006997.V340627.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Manley Court Nursing Home DS0000006997.V340627.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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