Inspection on 15/06/07 for Manor Court

This inspection was carried out on 15th June 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

Manor Court 22/11/06

Manor Court 14/10/05

Manor Court 04/05/05

Manor Court 14/09/04

Manor Court 28/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Manor Court 257 Blandford Road Efford Plymouth Devon PL3 6ND Lead Inspector Stella Lindsay Key Inspection (unannounced) 15th June 2007 09:45a 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 Manor Court DS0000003540.V337072.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. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Court Address 257 Blandford Road Efford Plymouth Devon PL3 6ND 01752 768425 01752 785781 debbie.gardner@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust 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) Debra Gardner Care Home 37 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (37), of places Physical disability over 65 years of age (37) Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. DE(E) Category for a maximum of 5 residents only Age 60 yrs To admit one named Service User aged 55 years. Date of last inspection 22nd November 2006 Brief Description of the Service: Manor Court is a care home providing personal care and accommodation for thirty seven people, over the age of 60, who may also have physical disabilities, five of whom may have dementia. The home does not provide intermediate care. The home is owned by Anchor Trust, a national voluntary sector organisation. The home was opened in 1990 and is a purpose built, two storey building situated in the residential area of Efford. It is close to local shops and amenities and public transport is easily available. The Registered Manager is Mrs Debra Gardner. All the rooms are for single occupation and are on the ground and first floors. They all have a small kitchen area and en suite toilet facilities. Thirty-four rooms also have en suite level access showers. In addition to the en suite facilities the home has three well-equipped bathrooms, which contain baths, showers and toilets. Two of the baths are assisted, one with a Jacuzzi system. There are also two separate accessible toilets. There is a combined dining and lounge room on the ground floor and a smaller lounge room on the 1st floor. The home has two passenger lifts and all areas are accessible by wheelchair users. Parking space is available at the front of the home, as well as on street parking nearby. The home has a garden to the rear of the property, with a patio accessible from the dining room. The fee levels are between £470 and £500 per week, although these may vary depending on the individual needs of service users. Information about the service can be obtained from the home, and the most recent inspection report was on display in the entrance hall. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days in June 2007. It involved a tour of the premises, and discussion with 14 residents, five visitors to the home, four staff on duty, the Registered Manager and the deputy Manager. Care records, health and safety records, staff files and the medication system were examined. Additional information about the running of the service had been supplied by the Manager prior to the inspection. Surveys and comment cards had been returned to the Commission for Social Care Inspection (CSCI) by residents’ relatives, professional visitors to the home and a random sample of staff, and their views are represented in the text. What the service does well: What has improved since the last inspection? Staff had undertaken training in Nutritional Profile Screening training, Falls awareness, safe administration of medication and Person Centred care in order to improve the safety of the service and care provided. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 6 Recording of personal and health care had been improved. A new format had been introduced, which encourages awareness of the resident’s individual needs and characteristics, and clarifies health care provision. Staff were taking more care to record details of health and well being including nutritional needs, so that they are more accountable for their work, and to improve continuity of care when new staff come on duty. The recording of medication had improved, to ensure that residents were given medication to promote their good health and avoid pain and discomfort. An Activities Organiser had been appointed, to improve the quality and variety of activities for residents. What they could do better: When assessing the needs of prospective residents, the person carrying out the assessment should be clear about the care and support that is needed and the home’s ability to provide this. This will help to make all admissions to the home as satisfactory as possible. Much information has been gathered in residents’ care plans, but the plans should contain a summary of the resident’s preferred daily routine with regard to personal care, health care, and social engagement, so that staff would be clear about what was required of them at any time. Sometimes it is necessary to record what residents eat, for instance if they are unwell or having difficulty in swallowing, and the Manager had introduced charts for this purpose. When making these records, staff should include the reason for any problem, and what they did about it. Bed rails should not be used without advice from health professionals, as their use can be hazardous. Risk assessments, for example, with regards to a resident’s likelihood of falling should include advice, so that staff work consistently to reduce the risk while enabling the person to remain independent. The management should ensure that anyone who makes a complaint to them considers that they have been given a proper response. There should be sufficient staff available to cover for inevitable absences, to implement the home’s own policies on ‘person centred’ working, and to enable residents’ needs to be met individually within and outside the home. Please contact the provider for advice of actions taken in response to this Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 7 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. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. Information for prospective residents is provided in a variety of ways. Managers assess peoples’ needs before offering accommodation, to ensure that residents needs can be met at the home. Intermediate care is not offered at Manor Court. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Anchor Homes provide an attractive folder in which the home presents its Statement of Purpose and Service User Guide. Up to date information is given about the staff, organisation, and facilities, and includes comments from residents. These are available in the home on request. Anchor also provide information on a DVD, and have a website. The most recent CSCI report was on display in the entrance hall. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 10 Two residents had been admitted recently. Their care records were examined and it was seen that they had been visited by one of the management team who had gathered information about their care needs in order to assess whether their admission to Manor Court was suitable. A new format had been introduced by Anchor Homes to record information gathered about a prospective resident in order to make a decision on whether Manor Court is suitable to meet their needs, and to prepare for their care. This was seen to have been used for the assessment of the two recently admitted residents. The form is well designed to assist a comprehensive assessment, but had not been fully completed. The sections entitled, ‘Describe whether the home can meet the Service User’s needs’, and ‘Description of care and support to be provided’ were blank, which suggests that more time could be usefully spent in considering the information that has been obtained, and in making preparations for admission. The Manager said that a standard letter is sent to new residents or their representative when the decision to offer accommodation has been made, though a copy was not kept on file. Service users and their relatives are welcome to visit the home prior to admission to meet residents and staff, and have a look around the home. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. Care planning is improving but still needs greater clarity and involvement of residents. Residents can be confident that they will be treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Anchor Homes have introduced a new format for care planning which will result in residents’ records being easier to understand, as different records, eg bathing, and health records will be brought together. This had been completed on behalf of one resident. It was seen to include a life history, medical history, an action plan to remove or reduce risks, and care plans with respect to personal hygiene, diabetes, prevention of falls, and mobility. Care plans should contain a summary of the resident’s preferred daily routine with regard to personal care, health care, and social engagement, so that staff would be clear about what was required of them at any time. Risk assessments should be written to give advice to staff on assisting the person to do the things that are important to them, while maintaining their safety. The new format should help the staff to consider this. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 12 Other residents’ records, which had not been transferred to the new system, were seen to be of variable quality, as some had personal or family histories, and some had a signature showing that the resident or their relative had been involved. One included information about a diabetic diet, but the food record showed that supper was not always given, suggesting a long gap between tea and breakfast for that resident. All would benefit from a summary, so that staff could be consistent in their knowledge of care required. One relative had written to the CSCI to say that their family member had been very unwell when they moved into Manor Court, and had recovered well – ‘thanks to the care and concern shown by all staff’. There was evidence of joint working with health professionals. Senior staff had requested advice from a dietician. Nutritional assessments are included in the care plans. Where there are concerns about a resident’s food intake, a daily chart is kept. Staff had become diligent at recording what each person had eaten, but most were failing to record either the cause of any problem, or what they did about it. Where bed rails were in use, a risk assessment had been signed by the resident, but health professionals had not been consulted. In Anchor Homes’ Summary of Terms and Conditions it is stated that a charge may be made for staff escort to hospital and GP appointments. This has not yet happened, and the Manager has ensured that staff have enabled residents to attend planned appointments, when there is no family willing and able to do this. Manor Court has a policy and procedure for the safe handling of medication. Staff were seen to be administering medication with care. A Senior Carer checks in each monthly order, oversees the proper running of the system and carries out a monthly audit. Records were accurate and reliable, with the exception of confusion in the recording of one individual’s medication, which was significant because the dosage was variable, but there had been no mistake in the drug taken. PRN medicines (those given on request of the resident, mostly painkillers) were carefully recorded, including how many were given, and any reason if they were refused. There is a suitable system for storage and recording of controlled drugs. There was a secure fridge in the office, for any medications that need to be refrigerated, and all residents have fridges in their own rooms. A suitable risk assessment format is available to judge and record a resident’s competence to look after their own medication. Most rooms have a lockable Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 13 drawer in which a resident could safely keep medicines if they wished to do this. Staff were observed treating all the residents with kindness, consideration and respect. However, one relative replied in a survey that they felt the staff treat all residents the same, in spite of their differing characteristics and life experiences. Staff would benefit from increased knowledge of residents’ past lives and achievements. The managers said that they aim to promote person centred care at Manor Court. Each private room has a telephone connection, and some residents have had a phone installed in their room. The office phone has a handset which may be taken to residents’ rooms for incoming calls to be received in private, and there is a pay phone with large numbers in a booth providing privacy. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. Management and many staff try to be flexible and to provide a service which is as individual as possible, but further progress is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most residents who spoke to the inspector were satisfied with their daily routines, including meal and bath times. Residents can have their laundry done when they like, but many like to know which is their regular day. Some were able to shower in their own rooms when they liked. One said they had not been able to have their bath the previous evening ‘because of a staff shortage’, but had it in the morning. An Activities Organiser had been appointed, who provided both group activities and individual attention. She was encouraging residents to keep a record of things they had enjoyed. She had drawn up a list of planned activities for the month, which included a visit by a worker from the Plymouth City museum, bringing objects and pictures for reminiscence; a visit by Pets As Therapy; a visit by ‘Body Shop at home’; relaxation, card-making; a visit by handbell ringers; a visit by a choir, with a cheese and wine evening. Bingo and salsa dancing took place during this inspection. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 15 A common theme during this inspection was a call from some residents, visitors, and relatives for more outings. Not all residents want to go out, but some would appreciate occasional individual attention from a carer, possibly their keyworker, for activities within the home, such as letter writing. Staff said that social activities had to be abandoned sometimes if they were short of a carer. Relatives returning surveys said that staff were ‘not visible much of the time’, and ‘inadequate to allow for full interaction other than at mealtimes’. A group of residents had prepared vegetables for lunch, and one helped to lay the tables. Changes to the garden were due to be discussed at a residents’ meeting later in the week. One resident said they enjoyed sitting out on the patio, and had enjoyed barbeques there. There is a small lounge on the first floor that is made available for family parties. The home has a link with a nearby school, and residents have been invited to events there. Church members collect residents to go to their local service. The Activities Organiser speaks to residents each week to see who wants to go. Overall, the quality and variety of the food was praised. The inspector joined the residents for lunch on the first day of this inspection, and was pleased to see that meals were brought to the table for residents to make their choice, of fish, chips and peas or sweet and sour pork. Twenty-six residents came to the dining room, which was spacious and light, overlooking the garden. Around six people were seated to each table, with condiments and sauces provided. Staff were quietly attentive. It was seen that some residents would benefit from rimmed plates, if they had poor sight or dexterity. The menu of the day was written on a blackboard in the dining room, though not every resident could see this. Special diets are catered for and, where required, nutritional plans are in place that follow advice given by doctors and dieticians. Fruit was supplied, and residents were given food to prepare as snacks or hot drinks in their own room. Manor Court DS0000003540.V337072.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 adequate. Complainants have not been made to feel that their concerns are being properly considered, although action has been taken to improve some systems in response. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager keeps a register of complaints made to the home. Since the last key inspection responses have been given to four formal complaints, all by relatives of residents at Manor Court. None of the complainants were satisfied by the response they were given. There were inaccuracies, omissions, and the feeling that the response they received was the ‘corporate view’, rather than addressing their particular concern. An unannounced inspection was carried out on 16th January to investigate issues that had been raised in a complaint, and several requirements made. At this inspection it was found that systems of administering medication and recording nutritional intake had been improved and staff training had been provided. The home’s register of complaints does not include actions that have been taken to improve practice, and does not include a record of minor concerns. A record was seen in a care plan of a report by a visiting friend or relative of missing jewellery. This had not been dealt with as a complaint, or any action taken. The Deputy Manager undertook to look into it. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 17 The home has a suitable policy for the Protection of vulnerable adults, and staff had received training. There was a sound system for safeguarding residents’ money, and checks are carried out on staff during the recruitment process, to protect residents from potential harm. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 26 Quality in this outcome area is excellent. Manor Court is well designed to promote residents’ independence, with easy access around the building, and suitable equipment. It is pleasant and well maintained, and provides a choice of social areas. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is purpose built, well maintained, spacious and adapted to accommodate people with physical disabilities. There are two shaft lifts, and four exits with level access to the grounds. The lounge and dining room are open plan and joined together. There is a smaller lounge on the first floor for minority activities or family gatherings. The residents said they enjoyed sitting out on the patio, and were interested in the new gardener’s plans. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 19 The long corridors have been painted in distinctive colours, to help people remember where they are. The Deputy Manager said that she is planning to discuss the choice of pictures at a residents meeting. One resident has pictures of themselves in their youth on their own door. It is planned to discuss with each resident what they would like, if anything, to mark their front door. Private accommodation for residents consists of a self-contained flat with a front door with letterbox and spy hole, so residents can check who is outside the door before they open it, should they wish to. They have doorbells with different sounds. Each flat contains a bed, comfortable seating and a kitchen area, as well as having en suite toilet facilities. Most of the flats (34 out of 37) also have en suite level access showers. All taps are thermostatically controlled, with the valves being checked weekly. Raised seats and grab rails had been provided in toilets as required. There is an assisted bath on the first floor which also has a popular Jacuzzi spa facility. There is an accessible shower in the same room. There is also a bathroom on the first floor which has an ordinary bath. No residents currently use it. It may be useful for someone trying out equipment before returning to their own home. On the ground floor there is another assisted bathroom, and two accessible communal toilets. There is a room for the residents to use for hairdressing and chiropody, which is good for privacy, hygiene and convenience. Bedroom doors are being fitted with well balanced closers, so that they will shut when the alarms ring, but otherwise will stay at any position they are put, so residents are in no danger of being crushed, and can keep their door open if they wish. Half had been fitted, and the others were due to be fitted in the following year. Each bedroom door has a suitable lock, so that residents may have privacy and security with no danger of getting locked in. Most rooms also had a lockable drawer. Some were awaiting this facility, which would be provided when their new kitchen area was fitted. The premises were clean and hygienic. The laundry had a good floor and tiled walls. There was a dedicated worker to deal with laundry, and a system in place that would keep clean clothes separate from soiled linen. The only flooring that was in need of replacement was in the chemical cupboard. Manor Court DS0000003540.V337072.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 adequate. Staffing levels were not sufficient to provide a good and consistent standard of individual care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a rota on display, which shows that there is one Team Leader and three carers on duty, as well as housekeeping staff and a laundress. The Manager, Deputy Manager, Administrative Assistant and catering staff were also on duty. The Manager considered that this should be sufficient, and that shortfalls could be dealt with by better time-management and supervision. However, this failed to take account of the need to be able to work with inevitable absences, to implement the home’s own policies on person centred working, and to enable residents’ needs to be met individually within and outside the home. The Team leader is engaged in administration of medication during the early morning period. This task was not completed till 11.30am on the first day of this inspection. Four residents currently need two carers for their care, leaving one for all other tasks. Relatives in surveys said that staff are ‘pushed to the limit when numbers are low’. One respondent wrote that, ‘long hours worked by staff sometimes - an accident waiting to happen’, but none of the rotas seen showed evidence of double shifts having been worked. Visitors to the home complained of having to wait at the front door, as no-one came to let them in. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 21 Staff and residents spoke of the difficulties that frequently arise due to an unexpected absence. No explanation was offered for high rates of sickness. Three shifts needed to be covered (and were covered) at short notice on the second day of the inspection. Staff reorganised their routines for the day, and were pleased with their teamwork, supporting each other to have a good day in spite of the difficulties. Considerable time and effort is put into covering absences, and staff anxiety was caused by shortage of people to call on, including night and weekend cover. The Manager was due to interview for bank staff on the following day. The effect on the social life of the home of insufficient staff has been documented in the section on Daily Life and Social Activities. An Activities Organiser had been appointed, and was introducing a variety of activities and interactions. The care team as a whole should consider social interaction as an important element of their work. As the Manager needs to introduce person centred practices throughout the home, it would be good practice to increase the levels of care staffing before increasing occupancy. BTEC induction training is provided by Anchor, which starts with the values required for good care. Staff confirmed that they have been provided with various training sessions and courses including health and safety, first aid, manual handling, fire safety, food hygiene, back care, dementia awareness and National Vocational Qualifications. Training on Person Centred Care was given on 15th & 17th January. Nutritional Profile Screening training was given on 2nd March and 2nd April. Falls awareness training had been booked for later in the month of this inspection. Designated staff had undertaken medication training. The files of three recently recruited staff were examined. All had written references, evidence that the candidate was not on the Protection of Vulnerable Adults (POVA) list, and an assurance by Anchor Homes that a Criminal Records Bureau clearance has been received. Manor Court DS0000003540.V337072.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 adequate. Management structures are provided by Anchor Homes, but further progress is needed to ensure that Manor Court is run in an open manner which is responsive to residents’ needs and promotes their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager, Mrs Debra Gardner, is appropriately experienced and qualified with the nationally recognised qualification known as National Vocational Qualification level 4 in Care, the Registered Managers’ Award and a Diploma in Management. One resident said – ‘she is all for the residents’. The Deputy Manager has also achieved the National Vocational Qualification level 4 in Care and the Registered Managers’ Award. The Responsible Individual for Anchor Homes is Mrs Jane Ashcroft, who is based at their London office. Anchor Homes has a management structure Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 23 which is included in information given to new residents, and includes local Area Support Home Managers. The organisation provides all policies and procedures, and support with environmental, financial, and human resource processes. There are two other Anchor homes in the Plymouth area, who also offer support. The on call system used to contact senior staff during the evenings and at weekends still needs to be more robust, as some expressed anxiety at the prospect of not being able to go home if they were unable to cover an absence. The Manager has stated that arrangements are being made for an on-call system in the Senior Team, which will include herself and her Deputy. Management are attempting to promote person centred care throughout the home, but still have some members of the team who are task-based. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. More work is needed in this area. A new system of individual staff supervision was being introduced, called Personal Development Discussions. Systems were in place for auditing processes in the home. Feedback had been gathered from residents and other interested parties. The Manager said that this has been used to prepare business plans and to analyse the home’s performance, though this was not examined at this inspection. There is a robust system for recording residents money that is looked after in the office, but only the Manager and the Home’s Administrator have access to it, so residents can only have money when they are available. There were about twenty residents who had chosen to use this facility, which may be excessive, as all have secure storage facilities in their room. Encouragement should be given, particularly to new residents, to look after their own cash, and efforts should be made to make them feel able to do this. Checks in care plans showed that records are generally up to date although some gaps are found in recording and entries are not always clear. Mandatory Health and Safety training is supplied. Moving and Handling training is given in the dining room, which means that residents can see staff practicing using the hoist and being hoisted, which may boost their confidence in the process. Fire safety training is given in the home. The Manager and Deputy Manager have attended a two-day training course given by a tutor from the Anchor training department. They then provide in-house fire safety training to the staff team. Manor Court DS0000003540.V337072.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 4 4 4 X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Manor Court DS0000003540.V337072.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 OP7 Regulation 15 Requirement The Registered Manager must ensure that the information contained within residents’ care plans and risk assessments is detailed, clear and unambiguous, so that staff know exactly what action they need to take to ensure that all aspects of the health, personal and social care needs of service users are met. Previous timescale 16/07/07 If residents refuse a meal or drink for any reason, those reasons must be documented, along with the efforts made by staff to encourage the service user to eat or drink. Previous timescale 16/03/07 The Registered Provider must ensure that there are enough staff on duty at all times to meet the differing needs of residents. Previous timescale 16/07/07 The Registered Manager must ensure that persons working at DS0000003540.V337072.R01.S.doc Timescale for action 31/08/07 2. OP8 17(2) Sch 4(13) 31/08/07 3. OP27 18(1)(a) 31/08/07 4. OP31 18.2 31/08/07 Manor Court Version 5.2 Page 26 the home are appropriately supervised, and comply with the plans, policies and procedures of the home. 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. 4. Refer to Standard OP3 OP7 OP8 OP16 Good Practice Recommendations The pre-admission assessment should be clear about the care and support that is needed, and the home’s ability to provide this. Residents or their representatives should always be involved in the drawing up and review of their care plans. Risk assessments with respect to the use of bed rails should include advice from health professionals, as their use can be hazardous. The home’s register of complaints should include actions that have been taken to improve practice, and should include a record of minor concerns, and management should ensure that complainants feel that they have been understood. Manor Court DS0000003540.V337072.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Manor Court DS0000003540.V337072.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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