CARE HOMES FOR OLDER PEOPLE
Manley Court Nursing Home John Williams Close Off Cold Blow Lane New Cross SE14 5XA Lead Inspector
Kate Matson Unannounced 21 - 22 June 2005, 10:00am
st nd 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 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 G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 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 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7635 4600 020 7639 9433 phil.moon@ansplc.co.uk ANS Homes Limited CRH Care Home 85 Category(ies) of DE Dementia registration, with number DE(E) Dementia - Over 65 of places OP Old Age PD Physical Disability PD(E) Physical Disability TI Terminally Ill TI(E) Terminally Ill Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 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 26th October 2004 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. 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 G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was carried out over 14 hours in two days. The inspection included speaking with ten service users, the Manager and Head of Nursing, the homes GP, one of the activities coordinators, and four visitors; touring the building and examining care plans and other records. It was noted that although the current manager had been in post since 1993, she had not yet been registered as manager of the home as required by the Care Homes Regulations. She stated she had applied in the past and had not received a response. A new application form was sent to the manager following the inspection and the manager was asked to submit an application as a matter of urgency. What the service does well: What has improved since the last inspection?
In addition to toileting programmes that were already in existence, clearer signs for toilets were produced and the home is now taking part in a study of Continence in Dementia in order to develop better strategies for continence promotion. Requirements made by the CSCI Pharmacy inspector regarding medication had all been met though further action is needed regarding storing medication at the correct temperatures.
Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 6 Refurbishment and redecoration works had been completed though further refurbishment is needed of the kitchen stairwell as this detracts from the overall environment and could lead to service users and staff feeling that they are not valued. A storage facility has been built though is not yet utilised to reduce the amount of equipment stored in the home. It is recommended that the manager write to the Primary Care Trust regarding ongoing problems with the collection of faulty and disused equipment. An occupational therapy assessment of the building has been completed and is still under consideration to ensure that service users have the specialist equipment they require to maximise their independence. Action had been taken on all of the recommendations of an infection control audit. What they could do better:
Only self-funding service users are provided with a contract with the home. The provider must ensure that all service users are provided with a contract so that all service users’ rights are protected. Care plans are comprehensive but need to evidence involvement of the service user or their representative in the care planning and review process. Service users’ healthcare needs appear to be largely met; however, recording in some instances is poor, so it is not clear that service users are getting the care that they need. Feedback about meals was mainly positive, however a student nurse seen standing over a service user whilst assisting her to eat was insensitive and disrespectful and the manager needs to ensure that staff assisting people to eat are trained to do so in a sensitive and respectful manner. There were some improvements in recruitment practices since the last inspection; however, one staff member had started employment in the home before a new check with the Criminal Records Bureau had been received and there was no evidence available that a check was made against the list of people considered unsuitable to work with vulnerable adults. This potentially places service users at risk of abuse. Also although it was a requirement at the last inspection, the provider had not ensured that staff have Disclosures from CRB England and Wales rather than CRB Scotland, which are not acceptable under the Care Standards Act legislation. However, the inspector was informed that this was because of a miscommunication at head office and action would be taken accordingly. There are some quality assurance systems in place; however, the provider must ensure that reports of monthly monitoring visits are also sent to CSCI to evidence that the quality of service is monitored, and an annual survey must be conducted to ensure that the service is developed in consultation with service users and other stakeholders, such as relatives and visiting professionals. Staff are generally well supported and supervised but the regularity of this could be better evidenced. The health, safety and welfare of staff are service users are promoted and protected though the times of fire drills need to be recorded to evidence that they are carried out at different times of day and night.
Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 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 standard(s) 2 and 3 Service users who are funded by local authorities do not have a contract with the home, leaving their rights unprotected. All service users have a full needs assessment before admission to ensure that the home is able to meet their needs. EVIDENCE: As at the last inspection, the manager stated that privately funded service users have a contract with the home, though service users whose fees are paid by a local authority have only a copy of the contract between the home and the local authority. The registered provider must provide all service users with a written contract to ensure that the rights of all service users are protected. Service users placed by a local authority had undergone a care management assessment prior to their admission to the home and copies of these were seen on files. The manager and/or the homes Head of Nursing also conduct an assessment of all prospective service users, at home or in hospital before admitting them to the home to ensure that the home can meet the needs of the service user. All of the files examined contained a copy of the home’s assessment and a resulting care plan.
Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 Care plans are comprehensive and regularly reviewed but do not evidence the involvement of service users and/or their representatives in the care planning process. Recording of care provided does not evidence that service users health care needs are fully met. Medication is well managed at the home though action needs to be taken to ensure that it is stored at the correct temperature. EVIDENCE: The inspector examined the care files of eight service users. Care plans are drawn up following completion of a number of assessments and risk assessments. They were regularly reviewed and covered all of the required areas. As noted at the previous inspection, although some files included a care plan consent form, care plan reviews were not signed to evidence the involvement of service users and or their representatives in the care planning and reviewing process. The home’s GP who was visiting on the day of the inspection was very complimentary about the home. He said that he felt the standard of nursing care was good, medications are well managed, and infection control measures have much improved. He added that the Manager and Head of Nursing are very hardworking and that the home is very well managed. Care records
Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 11 generally indicated that service users health needs are addressed and monitored, and specialist advice is sought where necessary, including tissue viability nurses, psychiatry, speech therapy, enteral nutrition team, physiotherapy and occupational therapy. However care records were not always accurate. For example one service users weight was recorded differently on the weight chart and the monthly summary and another service user’s records indicated that they had not seen the chiropodist for over six months though the manager stated they had been seen two weeks previously. Several service users had pressure sores though some of these had developed following hospital admissions. The care and treatment of these was being properly recorded and advice from tissue viability nurses was also evidenced. Since the last inspection, following a complaint made to CSCI, some care records supplied showed that although a service user had pressure sores, they were not being turned as regularly as they should have been. At this inspection again a turning chart indicated that the service user was not being turned regularly enough. The manager was confident that service users are turned as regularly as they should be but staff are not recording appropriately. This must be addressed to evidence that service users health care needs are being met. The home is participating in a national study about Continence in Dementia and the manager hoped that this would ensure that better strategies of continence promotion could be developed as required by the last inspection. During the inspection the manager produced some signs for toilet doors to aid continence in those with Dementia. The CSCI pharmacy inspector completed a full audit of medication policies and procedures at the last inspection. At this inspection the requirements and recommendations of that audit were followed up and a small sample of records and stock were examined. It was noted that the manager has taken appropriate action in accordance with the requirements and recommendations made, and records and stock were all in order. However although the temperatures of the medication room and the fridge were being recorded as recommended, insufficient or no action was taken when the temperatures were outside those recommended. For example, the fridge temperature had been recorded as 14 C (6 C higher than recommended) and the room temperature had reached 30 C (5C higher than recommended) and the window was opened. More effective action needs to be taken to ensure that medication is stored at safe temperatures. Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12 and 15 Service users were satisfied that the home meets their social, cultural, religious and recreational needs. Service users receive a good diet though the practice of a staff member seen standing to assist someone to eat is insensitive and disrespectful. EVIDENCE: Service users confirmed that they exercise choice in relation to relationships, religious observance and routines of daily living such as getting up and going to bed times, meal choices, and where to take meals. On the day of the inspection, some service users were seen taking meals in their rooms and others chose to eat in the dining rooms. The home employs two activities organisers and the homes weekly activities timetable was seen to include ‘oneto-one’ sessions with individual service users. Activities include, manicures, and massage, arts and crafts, bingo sessions, shopping trips, exercise to music, sing-a-long sessions and videos. Some service users had been involved in planting raised flowerbeds in the garden. Some service users attend day centres. One service user said that the activity coordinator takes her out every week and another showed the inspector some embroidery she was working on. Service users generally gave positive feedback about the food. They confirmed that they are offered a choice of meal the day before. Food surveys are conducted regularly and the cook meets with service users individually where they have raised any concerns to resolve them. One relative stated that she
Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 13 has found soup to be served dangerously hot on some occasions. Action was taken by the manager on the day of the inspection to ensure that food is served at safe temperatures. Mealtimes appeared to be relaxed and unhurried though it was noted that one student nurse was standing up whilst helping someone to eat. This is insensitive and disrespectful and it is of concern that when asked why she was choosing to assist the person in this way she replied that she wanted to stand up and appeared unconcerned about the wishes of the service user. The manager spoke to the student following this incident but must ensure that all staff assisting people to eat are trained to do so in a sensitive and respectful manner. Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 Records of complaints investigations indicate that they are taken seriously and acted upon. EVIDENCE: The complaints procedure had been updated to reflect the new name of the commission as required by the previous inspection. All of the service users spoken to said they had never had any reason to complain. One relative said they had made complaints and these had been responded to satisfactorily. The manager sends reports of complaints investigations to the inspector and these have always shown a thorough investigation has taken place and appropriate action has been taken. Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19, 20, 21, 22, 23, 24 and 26. Service users live in a safe environment that is generally well maintained though one area detracts from this and could lead to service users and staff to feel they are not valued. The environment offers single en suite accommodation and a range of communal spaces of adequate size. There are sufficient toilet and bathroom facilities. A recent occupation therapy assessment is still under consideration to ensure that service users have the specialist equipment they require to maximise their independence. Service users rooms are appropriately furnished and many have personal possessions around them. The home is clean and hygienic and it is hoped that some new strategies for continence promotion will improve the ongoing problems with unpleasant smells in the home. EVIDENCE: The home is purpose built and offers single, en suite accommodation with adequate personal and communal space. 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. The home is bright and airy and
Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 16 decorated and furnished appropriately. It is generally well maintained. Refurbishment as required by previous inspections had been completed though it was noted that the kitchen stairwell was now badly in need of refurbishment. The carpet was badly stained and the stairwell needed redecoration. This detracts from the overall environment and could lead service users and staff to feel that they are not valued. An outside storage facility was being completed in order to free up space internally for hoists etc as required by previous inspections. The manager reported that she continues to have difficulty with the collection of faulty or disused equipment. Although the manager has made numerous telephone and email complaints, it is recommended that she write a letter to the Primary Care Trust to try to resolve this ongoing issue. An occupational therapy assessment had been completed as required by previous inspections and the manager was still considering the recommendations as the report had only recently been received. This will be discussed further at future inspections. Service users rooms were furnished with the appropriate items, though one relative noted that there was no chair in the service users room. This was rectified on the day of the inspection. The home was clean on the day of the inspection though unpleasant aromas were still evident in some areas. Carpets had been replaced in consultation with service users and relatives as required by a previous inspection and some had chosen alternative coverings. The manager hopes that the national study on Continence in Dementia in which the home is taking part will assist in developing better strategies for continence promotion as well as the toileting programmes that are already in place. In addition she was producing some signage for toilet doors on the day of the inspection that should also improve the situation. As a result of a complaint, an infection control audit was carried out and action had been taken in response to all of the recommendations made. Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 There had been some improvement in the homes recruitment practices, however one staff member had commenced employment in the home before a check was made against the POVA list, placing service users potentially at risk of abuse. EVIDENCE: Ten staff files were examined and all of these contained proof of identity, two references and a disclosure from the Criminal Records Bureau (CRB). However two staff members had started employment before a new CRB check was received and there was no evidence available that a check had been made against the list of people considered unsuitable to work with vulnerable adults (POVA). The manager stated that one of these people was already an employee at another ANS home and both had recent CRB disclosures. She understood that a POVA check had been made but there was no evidence available to support this. This places service users potentially at risk of abuse and was an immediate requirement at the last inspection. In addition it was also a requirement at the last inspection that existing staff have disclosures from the CRB England and Wales as the company was using CRB Scotland, which is not acceptable under the Care Standards Act legislation. Although the inspector had received confirmation from ANS that this would be rectified, this had not been done. However on the day of the inspection the inspector was informed that this had been the result of a miscommunication at head office and existing staff would also have disclosures from CRB England and Wales. Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36 and 38 There are some good quality assurance systems in place but an annual survey of service users and others views, is needed to ensure that the home is developed in accordance with those views. Staff are appropriately supervised though the regularity of this could be better evidenced. The health safety and welfare of service users and staff are promoted and protected though one aspect of fire procedures does not reflect best practice. EVIDENCE: There are a number of systems in place to ensure the quality of service provided. The manager conducts monthly audits of care plans, medicines and cleaning. Monthly monitoring visits by the provider are conducted though copies of these reports have not been sent to CSCI as required. The manager has also devised a care review form, including the views of service users and relatives, that is to be used at individuals care reviews. It is an excellent form but has yet to be approved for use by ANS. There is also a food survey conducted regularly and a suggestions and compliments box is located in the
Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 19 reception area. All information packs in service users rooms include anonymous surveys for service users and relatives to complete at any time, however this needs to be formalised to an annual survey to canvass views of service users, relatives and other visitors to the home. Staff are supported by regular meetings on each unit. Supervision files show that most staff are supervised regularly. A previous recommendation that the supervision record is signed by supervisee and supervisor, when supervision takes place and a reason is recorded when supervision does not take place has not been implemented and therefore does not fully evidence that all staff are supervised as regularly as required. The home has appropriate health and safety policies in place. The organisation uses a health and safety consultancy to conduct regular inspections. Health and safety checks are carried out monthly. Risk assessments cover a variety of practices in and outside the home. There are window restrictors, water temperature regulators and low surface radiators in place. The home has an annual Legionella assessment. Moving and handling measures are safe. Gas safety and electrical installation and electrical appliance safety certificates were seen to be up to date. Lifts, hoists and other equipment is regularly serviced and inspected. It was noted on the day of the inspection that some call bells were missing and an order for replacements was made. The home’s fire alarms and equipment are regularly tested and serviced and fire drills held appropriately though it was noted that the time of the drill is not always recorded as required to ensure that these are completed at different times of day and night. Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 1 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2
COMPLAINTS AND PROTECTION 2 3 3 3 3 3 x 3 STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x x 3 x 2 Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 21 No Are there any outstanding requirements from the last inspection? 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 2 Regulation 5 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 not met) The registered person must ensure that the person or their family are involved in the drawing up and reviewing of care plans.(Previous timescale of 31/10/04 not met) The registered provider must ensure that all records of assessments and care given are completed thoroughly and accurately including dates and staff signatures.(Previous timescale not yet expired) The registered provider must ensure that good practice in pressure area care is followed at all times.(Previous timescale of 31/05/05 not met) The registered provider must Timescale for action 30/09/05 2. 7 15 (1) and (2) 30/09/05 3. 8 17 (1) (a) 30/06/05 4. 8 12 30/09/05 5. 9 13 (2) 30/09/05
Page 22 Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 6. 15 12 (4) (a) 7. 19 23 (2) (d) 8. 29 19 (1) 9. 29 19 (1) 10. 33 26 11. 33 24 ensure that where fridge and room temperatures go outside the required range for safe medication storage, appropriate action is taken. The registered provider must ensure that all staff assisting service users to eat are trained to do so in a sensitive and respectful manner. The registered provider must ensure that the kitchen stairwell is refurbished including replacement flooring. The registered provider must not allow any new staff to commence employment in the care home before the receipt of 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.(This was an immediate requirement at the last inspection) The registered provider must ensure that a disclosure from CRB England and Wales and two satisfactory written references are in place for all existing staff, and are available for examination at future inspections.(Timescale of 26/10/04 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) 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. 30/09/05 31/12/05 22/06/05 31/10/05 30/09/05 31/10/05 Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 23 12. 13. 38 31 23 (4) (e) 8 (1) The registered provider must ensure that the time of fire drills is recorded. The registered provider must ensure that the manager of Manley Court is registered in accordance with the Care Homes Regulations. 30/09/05 30/11/05 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 22 33 36 Good Practice Recommendations It is recommended that the manager writes formally to the Primary Care Trust regarding the ongoing problems with the collection of faulty or disused equipment. It is recommended that the care review form devised by the manager be put into operation as soon as possible. It is recommended that the supervisee and supervisor sign the supervision record when supervision takes place and when supervision does not take place a reason is recorded Manley Court Nursing Home G52-G02 S6997 Manley Court V235082 21220605 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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
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