Inspection on 26/02/07 for Manor Court

This inspection was carried out on 26th February 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Manor Court 06/07/10

Manor Court 26/04/10

Manor Court 14/04/10

Manor Court 23/02/10

Manor Court 14/03/08

Manor Court 30/06/06

Manor Court 18/10/05

Manor Court 27/04/05

Manor Court 04/11/04

Manor Court 04/08/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Manor Court 31 Churchfield Lane Darton Barnsley South Yorkshire S75 5DH Lead Inspector Mrs Sue Stephens Key Unannounced Inspection 26 February 2007 11:00 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 DS0000018271.V319802.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 DS0000018271.V319802.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Court Address 31 Churchfield Lane Darton Barnsley South Yorkshire S75 5DH 01226 382321 01226 381299 none 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) Southern Cross Care Centres Limited Vacant Care Home 32 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (22) of places Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The DE(E) unit is on the first floor of the home. Can provide accommodation and care for two named service users aged under 65 years of age. 30th June 2006 Date of last inspection Brief Description of the Service: Manor Court provides residential care for older people; the home has 38 beds. It is in the village of Darton with easy access to shops, post office, church, local village club and health centre and it is on the main bus route. The home accommodates people on two floors and there is a passenger lift. Manor Court has 28 single bedrooms, 7 of which are en suite and 2 double bedrooms. The upper floor accommodates 10 people. The home has 5 lounges and 2 dining rooms. There are extensive gardens, with lawns and an enclosed area, garden furniture and a water feature. There is parking at the front of the building. The fees range from £327 to £356 per week. Additional charges include hairdressing, chiropodist, toiletries and transport. These charges are variable; the manager can provide more information about this. People who are interested in Manor Court can get information by contacting the manager. The home will also provide a copy of the statement of purpose and the latest inspection report. Inspection reports were available at the home in entranceway. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced; however the manager was informed the visit would take place at the beginning of the week. This allowed the manager to change leave arrangements and be present for the visit. It took place between 11:00am and 17:15pm. The inspector sought the views of five residents, seven relatives (five on the phone), two care workers and the assistant cook. The manager, Linda Knowles assisted with the inspection. CSCI are in the process of registering the manager. This visit was a key inspection and the inspector checked all the key standards. During this visit the inspector looked at the environment, and made observations on the staffs’ manner and attitude towards the residents. She checked samples of documents that related to the resident’s care and safety. These included three assessments and care plans, three medication records, and three staff recruitment files. The inspector looked at other information before visiting the home. This included the pre-inspection questionnaire, which the Commission for Social Care Inspection (CSCI) had requested. The inspector also looked at the following information requested by the commission: • 3 resident surveys • 10 relative/visitor comment cards • 2 professional in contact with the home comment cards • 1 staff questionnaire The CSCI carried out a random inspection at the home on 28 November 2006. The visit looked at medication systems, some previous requirements and information about a complaint. The inspector would like to thank the residents, relatives, manager and staff for their welcome and help in this inspection. What the service does well: Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 6 They provide residents with good assessments and care plans; these give staff clear instructions about how to provide safe and consistent care. Relatives said they were satisfied with their family members care and made a lot of positive comments, these included, “It is very good” (at the home) “The carers have a caring attitude” “They care for residents as people, not just residents” Staff treated residents with dignity and respect; they were polite and friendly towards people. And staff knew how to encourage people to continue to make their own decisions and maintain their independence. The home offered support to residents who needed help to manager their finances, or to keep them safe. Residents had access to plenty of drinks, and the home provides tasty and nutritious meals. Relatives said they were confident about raising concerns and complaints, and that the manager and staff listened to them and took action. Staff had very good training over the past year; this included safeguarding vulnerable people, health and safety, nutrition, dementia awareness and customer care. Fifty percent of the staff also had a National Vocational qualification in care. The manager and staff made the environment comfortable and homely. And the bedrooms were fresh and clean. The relatives said a lot of positive comments about staff, they said, “Staff are really caring people, always smiling and happy to chat” “Staff work very hard” “I think the staff are caring and committed to the work they do”. Southern Cross Care Ltd visited the home and made regular checks on the standard of care, satisfaction of the residents, and safety of the home. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Improve some more medication practices to make sure staff administer medications safely. The home needs to monitor residents’ activities and make sure they meet people’s social needs. They need to make sure people’s access to activities, fresh air and the community continues to improve. This needs to include people who live upstairs and people who have mobility needs. Staff need to understand people’s dietary needs better, for example people who need liquidised, soft or chopped meals. The manager needs to make a record on the residents finance sheets when she has audited to show that the money is checked and correct. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 8 The home needs to review the staffing levels to make sure they meet people’s health, welfare and dignity and comfort needs. And they need to review handover procedures to make sure staff share important information about the residents. The home needs to inform the Commission for Social Care Inspection if someone has died at the home. This is because it is a regulation that all homes must comply with. 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. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 9 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 DS0000018271.V319802.R01.S.doc Version 5.2 Page 10 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): 2 and 3. The home did not provide intermediate care at the time of the visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents have a contract with clear terms and conditions. They have good assessments so that the home can confirm it can meet their needs. EVIDENCE: The home had made good improvements to residents’ contracts since the last key inspection. The inspector checked three contracts; these gave good information about peoples terms and conditions. There was information available about individual fees and the contract identified the room allocated to the resident. The home had improved residents’ individual assessments. The home carried out their own assessments with the residents; this was in addition to social or Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 11 health care assessments carried out by placing authorities. This provided good detail and information to help the home identify individuals’ social and health needs and personal preference. The home drew up people’s plans of care from information in the assessments. There was also evidence that the home had reassessed people when their needs had changed. This was good practice. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans set out the needs of the residents and instructed staff how to give appropriate and consistent care. The plans and care at the home met people’s health care needs. The home had made good improvements to the medication systems. This was now safer for the residents. In the main the home cares for people with dignity and respect, relatives’ positive comments confirmed this. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 13 EVIDENCE: People at the home had good care plans; these included in-depth information about their needs. The home had made good improvements on these since the last key inspection. The random inspection also checked this and identified good improvements. The format of the plans made sure that staff could find out a lot of information about an individual including their preferences, their health and social needs and information about their past lives. This helped staff to make sure they offered appropriate support and care. Two relatives said they were satisfied with their family members health care. They confirmed that the home made sure their family members had access to G.Ps and other health care services such as optician, dentist and chiropody. Where possible the home asked relatives to accompany their family member to hospital and other health care appointments. The care plans described people’s health care needs, and the plans were clear about the action staff must take to support them. The care plans included peoples oral hygiene needs, skin and pressure care, continence, mental health and nutrition. In the main the manager and staff had made very good improvements to the homes medication procedures. These were now much safer. Some staff had received training, and the manager had instructed all staff about correct administration, recording and storage procedures. The home had met most of the requirements and recommendations made by the CSCI pharmacist on the random inspection visit. The inspector checked three medication records; these identified the following: • Staff did not use consistent codes to record why the resident did not have their medication. This could lead to medication administration errors and poor health monitoring. Hand written instructions on the MAR (medicine administration record) did not have two signatures to confirm staff have checked the instructions and that they were correct. The home did not have a record of staff initials with their signatures. This is necessary to identify who has recorded on the MAR sheet. DS0000018271.V319802.R01.S.doc Version 5.2 Page 14 • • Manor Court • The carpet in the upstairs medication room was sticky. This was close to where medicine was stored and suggested someone had split medicine and not cleaned it up. Staff treated people at the home with dignity and respect. The relatives said about their family members’ care: “It is very good, the staff are friendly and helpful” “My mum always looks clean” “Mum is well cared for, she loves it here” “She (family member) always looks clean and tidy” “The carers have a caring attitude, they care for them (the residents) as people not just residents, the staff learn about individuals likes and dislikes” However relatives also expressed concern about low staffing levels, this did affect peoples dignity and choice, for example one relative said their family member had to wait a long time to go to the toilet, and another expressed concern that when two staff supported an individual to go to the toilet, this left the rest of the residents with out staff to support and observe them. See standard 27 for more information and the requirement about this. The inspector spent time observing staff and residents together. Staff interacted with residents in a polite and friendly manner. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although relatives expressed concern about residents’ social activities the home had taken recent action to address this. The home needs to continue to monitor this to make sure they meet people’s social needs. Residents were satisfied with the meals and there was good practice to encourage residents to drink fluids. The home did not fully understand some dietary needs. And liquidising all ingredients of a meal together is poor practice. It does not consider a persons choice, taste and dignity. EVIDENCE: Relatives said activities at the home had not been good. For example they said: Residents are “Often sat about doing nothing, sometimes not even the T.V on” Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 16 Activities upstairs are “limited” and “they (upstairs residents) are not included with people downstairs” “There is not enough access to outside and fresh air, because some people are immobile” “When it’s nice in the summer there are areas outside – but because of lack of staff they (residents) don’t get these opportunities. However some relatives said that over the past week opportunities to do activities had improved. The manager said they had now recruited an activities co-ordinator who would look at all people’s activity and social needs. One relative said she had met the coordinator, and was impressed because the coordinator had made an effort to introduce herself, and took time to chat with the residents. Another relative who expressed concerns also said about their last visit to the home “but the new coordinator was playing games, and every one was involved” they said, “It seemed a lot better”. “I think the coordinator is trying to organise bringing pets into the home. The residents will like that”. Staff said about resident activities and community contact, “There are not enough staff if they (residents) want to go anywhere”. “We do try to take people to the shops if they want to go, there is a local shop across the road.” “We took a few people out for a walk last week” “The coordinator has bought new paints, equipment and musical instruments for the residents” The inspector spent time with a group of residents. She noted that staff interacted well with the residents, they encouraged residents to play dominos and do table top activities. The relatives said staff always made them welcome when they visited. Staff described how they encourage people to choose their own daily routines and make choices. They said, “We try to offer them safe options” “Some people we can show cards to help them understand” “I hold two sets of clothes up so that the resident can choose what they want to wear.” Both staff said they had completed a National Vocational Qualification and one said they had just started a dementia care course. The training covered how to support people to maintain their autonomy and choices. And one staff said they were involved in doing a “life book” with a resident. This was good Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 17 practice and showed that staff understood how important it was that residents have as much choice and control over their lives as possible. Residents could look after their own finances, if they needed support the home had goods systems on place so that residents could access their money and see evidence of accounts. Residents and relatives said they thought the meals at the home were good. Some relatives stayed with their family members during meals. They could have a meal with their family member if they wished. One relative said “I have been coming a while and have always enjoyed the meals with my (family member). The home had varied menus that included nutritious foods. There was a choice and the assistant cook said “or people can just tell me what they want, and we’ll cook it”. She also said “the cook goes out every morning to check what people want”. The inspector observed a staff supporting a resident to eat. The staff sat with the resident and the event was unrushed. The staff spoke to the resident during the meal and helped the person in a dignified way. The kitchen staff did not have sufficient information about peoples special dietary needs. For example they did not know if people needed chopped, soft or liquidised diet. And for one person assumed their meals needed liquidising. The kitchens did not separate liquidised meals. For example they liquidised all the ingredients of the meal together. This did not promote people’s dignity and enjoyment of food. The inspector advised the assistant cook to look at alternatives such as serving meat, vegetables and potatoes liquidised separately. The inspector noted that staff offered residents drinks on a regular basis. In the downstairs lounge staff placed three jugs of juice and glasses for residents to help themselves. This was good practice because it helped residents maintain independence and have access to drinks without being dependent on staff. One staff said that the residents were very good at pouring drinks for each other; this promoted social contact and activity. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home listens to resident and relatives concerns, and takes action about the concern. Staff are trained and understand how to protect residents from harm and abuse. EVIDENCE: Relatives said they felt they could complain on behalf of their family members and the home would listen and take action. Eight of the relatives comment card returns confirmed that they were aware of how to complain. Relatives, who the inspector spoke to on the phone, also confirmed this. Relatives said, “If there is a problem with Mum I can go to see Linda (the manager)” “I’m not the sort of person to complain, but I know I could go to the manager” “I could complain to the staff” Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 19 Another relative said when they complained the manager listened and apologised and sorted the situation out. The homes complaints procedure was on display in the entrance hall. The information about how to contact the Commission for Social Care Inspection was on display on a separate wall to the first page of the complaints procedure. This could be confusing, and the manager agreed to display the information together. The manager confirmed that all staff had protection of vulnerable adults training. The homes training matrix showed that 100 of the staff had received this training. And the staff who were interviewed knew where to find the policies and procedures for guidance and understood the whistle-blowing procedures. The home had improved the finance systems; these were accessible and easy to understand. The inspector checked a sample; and found receipts and signatures relating to what the residents had spent. The manager said the organisation comes in twice a year to audit finances at the home. The manager said she checks the finance records and monies monthly. The manager had not made a record of her checks, this meant that she did not have evidence to show she had checked the monies and that they were correct. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 20 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes environment meets the needs of the residents. EVIDENCE: The home was clean, free from offensive odours and looked homely and inviting. The manager and staff had made extra efforts to make Manor Court homely, interesting and comfortable. For example upstairs the corridors had focal points and items of interest that the residents could handle, rearrange or move. This included a lattice threaded with artificial flowers. Some residents enjoyed rearranging this or spending time weaving the flowers in the lattice. The display was colourful and dignified and stimulating for the people who were interested in it. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 21 The home had redecorated some of the bedrooms. The home had done these to a high standard and the bedrooms were fresh, clean, and dignified. One relative made comments about the homes environment and said, “The manager has improved the place tremendously” The home kept the furniture clean and well maintained. The home had taken action following the last requirements and refurbished parts of the kitchen. The kitchen was clean with suitable fittings and equipment. The laundry facilities were suitable for the needs of the residents. The residents’ clothes looked clean and well laundered. The training matrix showed that 92 of the staff had training in infection control in the past 12 months. This has been a good achievement and is good practice to minimise the risk of cross infection at the home. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has improved staffing levels, however some relatives are still concerned that this is not enough for the residents needs, health and safety. The home’s staff training achievements are a huge benefit to the residents; staff are equipped to provide safe, professional and consistent care. The home recruitment practises help safeguard the residents. EVIDENCE: The relatives made a lot of positive comments about the staff, they said, “Staff are lovely” “Staff are really caring people; always smiling and happy to have a chat” “The staff are marvellous, they idolise my dad” “Linda (the manager) and her staff are always very supportive of ‘Nan’ they show genuine care and compassion” “Staff work very hard” “I think the staff are caring and committed to the job they do”. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 23 Several relatives raised their concerns about the staffing levels at the home. They continued to praise the staff and said it had started to improve. The relatives made these comments, “Staffing shortages sometimes result in having to wait too long for the toilet and for help” “On a couple of occasions at weekends only one carer was on for the upstairs unit, I ended up helping to feed and take my (family member to the toilet” “At weekends quite often only one person on, the other is off sick or downstairs” “Staff work very hard and do not have a lot of time to spend with individuals” “Things have improved there are always two people on (upstairs) but with 10 people on the unit with severe disturbances it is difficult for staff to cope, particularly at meal times and if anyone wants to go to the toilet” “Sometimes it takes ages and ages for the staff to answer the door, and there is no staff around” “I have noticed if someone goes off sick there is just one carer upstairs, it puts the safety of the residents in question. Also it is unfair on the staff” “At break times this happens (one staff upstairs); or staff don’t get breaks” “When some one wants to go to the toilet the staff have to leave every one else”. The manager said this had improved. However some relatives said they were still concerned that the home sometimes leaves people upstairs with one carer, while the other takes their break. Other relatives asked that if someone needed two carers, for example to help toileting or turning, who was left to look after the other people? It was evident from the number of relatives that raised this concern that although they were happy with the staff they were worried about the residents welfare on the staffing levels provided. The relatives raised these concerns direct to the inspector, on the phone to the inspector, and via the comment cards. The inspector made the manager aware of the concerns from the comment cards during the visit to the home. (The inspector kept the relatives identity confidential). The home did not provide staff with time to hand over information to the following shift. The manager said staff did pass information on and there was a communication book. Verbal hand-over relied on staff arriving early before their shift; this was not good practice because it could lead to staff missing important information about the residents. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 24 Eight out of sixteen care staff had achieved a National Vocational Qualification in care at level 2 or above. This met the National Minimum Standard whose out come is that residents are in safe hands at all times. The home kept well-maintained recruitment files on staff. And information was available to show that they gave staff thorough checks before offering employment. Some staff files did not have a current photograph. This is necessary for the home to comply with legislation and check peoples identity. The manager confirmed that they now supervise new staff until their criminal record bureau check is complete. This safeguards the residents. The home had provided staff with appropriate training to give them the skills and knowledge to care for the residents. A training matrix showed that the home had excellent training attendance and they had monitored this over the past 12 months. They had given almost all staff retraining over the past 12 months. The inspector commended the manager and staff for this achievement. Staff training included health and safety, nutrition, pressure care, care planning, dementia awareness and customer care. It was evident from the good care practises and the satisfaction of most of the relatives that the training had a good impact. It gave staff good skills and enhanced the health and welfare. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 25 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): 33, 34, 35, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has effective quality assurance systems. These include health and safety, and finance. This promotes the best interests of the residents. EVIDENCE: The inspector did not check standard 31 because the manager had applied to the commission for registration. This process was not complete at the time of the visit. The manager had made good progress and introduced the organisations quality processes to the home. For example good practices around training and recruitment, improved care plans drawn up to company good practice policy Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 26 and good health and safety documentation. The area manager visited the home and made reports on the home back to Southern Cross Care Ltd. Records showed that the home had not notified the Commission for Social Care Inspection about a resident who had died. This is a regulation (Care Homes Regulation 2001) that the home must comply with. The area manager confirmed that she and other senior managers from Southern Cross monitored the homes finance procedures. The manager said there was sufficient budget for the home. She said Southern Cross had been “very good” at providing furnishings and fittings for the home. The home had improved records on residents’ finance. The records were easy to understand and accessible to the individual residents. See standard 18 for recommendation. Staff had training in health and safety and safe working practises. There was further training planned for staff who needed updates, for example in first aid. The home had health and safety policies and procedures and these were available to the manager and staff. Safety check records included fire, maintenance, water and accidents, the records were accessible and easy to follow. Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 27 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 3 3 X X 3 Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP15 Regulation 13 Requirement The home must make sure staff understand people’s individual dietary needs, for example liquidised, soft or chopped meals. People who need their meals liquidised must have these served in a dignified manner. The home must not liquidise all the foods together, unless an individual requests this. The home must refer people who have changing or uncertain dietary needs to the dietician or appropriate health care service for assessment. The home must review the staffing levels. This must include: • Residents welfare and safety • Consultation with relatives and visitors • Residents and relatives wishes and preferences The home must take action on Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 29 Timescale for action 31/03/07 2 OP27 18 30/04/07 3 4 OP29 OP33 19 schedule 2 37 the outcome of the review and make sure the staffing levels are adequate for the safety, comfort, dignity and wellbeing of all the residents. Staff records must include a recent photograph. The home must notify the commission about deaths. This must include the circumstances of the individual’s death. 31/03/07 31/03/07 Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 1 OP9 The use of codes to record medication that has not been given must be consistent and identifiable on the medicine administration record sheet (MAR). (The above recommendation is carried forward from the random inspection 28 November 2007). Hand written instructions on the MAR should have two signatures to confirm staff have checked the instructions and that they are correct. The home should have a record of staff initials and signatures so that these can be identified if needed. The home should instruct staff about the importance of cleaning up spills. The carpet should be cleaned. 2 OP12 The home should monitor residents’ activities to make sure their social needs are met and the access to activities continues to improve. The home should look at ways of improving the residents’ access to outside and fresh air. In particular for people who live upstairs or have difficulty with mobility. The manager should make a record on the finance sheets when she has audited to show that the money is checked and correct. The home should review handover procedures to ensure staff have sufficient time to hand over information that it is thorough and effective. 3 OP13 4 OP18 5 OP27 Manor Court DS0000018271.V319802.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000018271.V319802.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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