Inspection on 06/11/06 for Manor Court Nursing Home

This inspection was carried out on 6th November 2006.

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 Nursing Home 21/11/05

Manor Court Nursing Home 07/12/04

Manor Court Nursing Home 21/07/04

Manor Court Nursing Home 23/04/04

Manor Court Nursing Home 17/11/03

Manor Court Nursing Home 29/07/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Manor Court Nursing Home Britten Drive North Road Southall Middlesex UB1 2SH Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 6th November 2006 10:25 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 Nursing Home DS0000010951.V317791.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 Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Court Nursing Home Address Britten Drive North Road Southall Middlesex UB1 2SH 020 8571 5505 020 8574 9243 jacksonpae@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Limited 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) Mrs Patsy Mary Jackson Care Home 120 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Mental disorder, excluding learning of places disability or dementia (0), Mental Disorder, excluding learning disability or dementia - over 65 years of age (0), Old age, not falling within any other category (0), Physical disability (0), Physical disability over 65 years of age (0), Terminally ill (0) Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of 30 service users over the age of 60 years with Dementia. A maximum of 60 service users with a Physical Disability of which 20 may be under 60 years. Three may require palliative care. A maximum of 30 service users over the age of 60 with Mental Disorder. 21st November 2005 Date of last inspection Brief Description of the Service: Manor Court is a 120-bedded purpose built care home, divided into four separate buildings, each of which is self contained having its own communal facilities. The home has 90 Continuing Care beds. The other 30 beds are funded by Ealing Primary Care Trust, Social Services and privately. All bedrooms are single rooms. There are no en-suite facilities. Service users access GP services via the homes own doctors, an allocated GP or through signing up with a GP of their choice. A consultant psychiatrist visits the home for service users who have mental health needs. The home is situated in a residential area of Southall, with a few local shops nearby. There are bus services that pass near to the home. The fees range from £650 to £950 per week, dependent on assessed need. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 24 hours was spent on the inspection process. A tour of each unit was carried out, and service user plans, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. The CSCI pharmacist Inspector carried out an inspection on 23/10/06 and a separate report is available. The requirement and recommendation from the pharmacist inspection have been incorporated in this report. 21 service users, 7 visitors, 20 staff and 1 healthcare professional were spoken with as part of the inspection process. The preinspection questionnaire and comment cards from service users and representatives have also been used to inform this report. 19 service user and 10 representative comment cards were received by CSCI. It must be noted that it is sometimes difficult to ascertain the views of service users with mental health or dementia care needs. What the service does well: The home is effectively managed, with an open approach and good leadership from the Registered Manager and the Deputy Manager. Teamwork amongst staff is good. Information about the services and facilities offered is freely available throughout the home. Service users are fully assessed prior to admission to ensure the home can meet their needs. Staff were observed interacting and caring for service users in a gentle and professional manner, and service users spoken with said that they are well cared for at the home. The home has an open visiting policy and visitors spoken with said that they are made very welcome at the home. The activity input in the home is good, with plans to increase this in the future. Overall service users spoken with expressed their satisfaction with the food provision and the Chef works hard to meet each service users needs. Shortfalls in the provision of some ‘soft’ diet items should be easy to address. Systems in place for the management of complaints and safeguarding adults are robust. The home is appropriately staffed and robust systems for vetting and recruitment are in place. Staff receive ongoing training to provide them with the skills and knowledge to meet the needs of the service users. Service users are encouraged to provide feedback on the service provided and good quality assurance systems are in place. Service users monies are being well managed. Staff receive regular supervision. Systems for the management of health and safety are in place. Written comments received from service users include: ‘I consider myself fortunate to have been brought to the home, and cannot imagine a more congenial place to spend my days.’ Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 6 ‘The staff are excellent and the standard of care is excellent’. ‘I am pleased with the care given to my relative. The staff are all polite and all seem to do their best’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with the information they need to make an informed choice about the home. Copies of the homes terms and conditions are available in each Service User Guide and also in the service users records, thus providing clear information for service users and their representatives. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. EVIDENCE: The home has a Service User Guide and Statement of Purpose and these are freely available to service users and visitors. The information is kept up to date. 90 of the beds are Continuing Care beds for which there is a block contract. The other 30 beds are a mixture of Social Services, Primary Care Trust and privately funded. Copies of the homes Terms and Conditions are in the Service Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 9 User Guide and were seen in the files of the service users who were case tracked. The home has a pre-admission assessment that is carried out for all prospective service users. These were seen in the service user plan documentation viewed and were comprehensive, giving a clear picture of the service user and their needs. Copies of Social Services and Primary Care Trust assessments, plus hospital discharge information were also available. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were up to date, thus providing staff with a clear picture of the service users needs and how these are to be met. Medications are being well managed at the home, thus safeguarding service users. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: Samples of service user plans were viewed on each of the units. Overall these were up to date and provided a good picture of the service users needs and how these are to be met. There was evidence of input from the service users and/or their representatives. The service user plans had been reviewed monthly and whenever a service users condition changes. There was evidence of new care plans being formulated to address any new needs identified. Risk assessments for falls were in place, and there was evidence that these had been updated following any falls. Representatives spoken with said that they are kept up to date with their relatives’ condition and contacted if there are any concerns. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 11 Documentation for wound care was in place. Pressure sore risk assessments were in place and there was evidence of updates when a service users skin condition had changed. Pressure relieving equipment was seen in use and had been clearly identified in each service user plan. On two units the record of wound dressing changes did not always tally with the stated frequency of changes in the assessment document. This was discussed with the Unit Managers at the time of inspection. On one unit the need for specialist health care input had been identified on the Social Services assessment, but there was no evidence that this had been followed up by the home. The Registered Manager said this would be addressed. Nutritional assessments were in place, and on one unit the Manager had identified the need for additional training to ensure all staff are clear on completing this document. Moving & handling assessments were thorough and identified the specific equipment to be used for each service user. Continence assessments were in place. Care plans for all identified needs had been formulated. Risk assessments for the use of bedrails had been completed, and written consents obtained. Risk assessments for other areas of risk identified had also been formulated, and the service user plans viewed on Sycamore House contained particularly thorough risk assessments. There was evidence of input from GP’s and other healthcare professionals. The CSCI Pharmacist Inspector carried out an inspection on 23/10/06 and a separate report is available. The requirement and recommendation resulting from that inspection have been incorporated into this report. The abbreviation ‘MAR’ stands for medication administration record. Staff were seen to care for service users in a caring, polite and professional manner. Staff knock on doors prior to entering service users bedrooms. Where service users require assistance with their meals this was done discreetly and sensitively. Service users and visitors spoken with said that the care provision in the home is to a good standard, and staff are approachable and helpful. Staff spoken with said that they work well together as a team. Service users individual items of clothing are labelled. Service users can bring in personal possessions, subject to fire safety. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are activities provided for service users with a programme in place, and service users specialist needs are also catered for. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is freely available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: The home has two activities co-ordinators and the Registered Manager explained that she is in the process of creating a further 20 hours per week for a third activities person. The activities programme was displayed in all units. Activities records viewed detailed any activities that service users had participated in. There was also a ‘Map of Life’ that service users and/or their families had completed, giving a clear social and leisure interest history for each individual. On Larch House the home had developed a reminiscence room and progress was being made with individual memory boxes. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and refreshments are offered. Service users can choose to receive their visitors in their own rooms or in one of the day rooms, depending on their own wishes. The home has an allocated advocate from the Local Authority, primarily for service users who do not have any representatives. Details for contacting them and also other advocacy services such as Age Concern, Alzheimers Concern and MIND are available in the home. Menus are displayed in the dining areas with details of the choices available. Service users choices are recorded. Religious and cultural dietary needs are catered for. One Inspector viewed the lunchtime meal, and service users were interacting well and enjoying their food. Service users spoken with expressed satisfaction with the food provision and confirmed that they are offered choices. A visitor also confirmed that the Chef is very accommodating and will provide different alternatives to meet the service users wishes. The kitchen was clean and tidy and all records viewed were up to date. There was a good supply of foodstuffs and the Chef said that mainly fresh produce is used, with some frozen produce used if necessary. Comment was received as to the good quality of the meat, and that it is well cooked. Meals are well presented and drinks and snacks are available throughout the 24 hour period. A cooked breakfast option is available. The provision of meals for service users who require a ‘soft’ diet, as opposed to a liquidised diet was discussed, as it was commented that inappropriate sauces are used to soften the food, for example, gravy served with an omelette. The Registered Manager said that this would be reviewed to ensure an appropriate soft diet is available for all service users who require this. Each unit has a kitchenette where essential supplies are available. An Environmental Health Inspection took place in August 2006 and a report of this visit was available. The Registered Manager reported that all recommendations contained therein had been addressed. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. The system in place for protection of vulnerable adults is robust, thus safeguarding service users. EVIDENCE: The home has a clear complaints procedure in place with timescales for action. There had been 19 complaints since the last inspection and the documentation viewed was comprehensive and evidenced that the complaint had been fully investigated and responded to. The home has policies and procedures in place for the protection of vulnerable adults, and this dovetails with the Local Authority Safeguarding Adults documentation. There have not been any POVA allegations since the last inspection. There was evidence that staff had received training in the management of physical and verbal aggression, and POVA training, with further training planned. Staff spoken with were very clear that they would report any concerns. There are procedures in place for the management of service users monies, and the staff handbook states clearly that staff must not accept gifts. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is evidence of works taking place to maintain the home, however additional redecoration and refurbishment programmes are required to provide a good standard of accommodation for service users. Some of the radiators were overheating, which could place service users at risk. The provision of equipment in the home is good, thus ensuring the service users moving & handling needs can be met. Systems for infection control are robust, however shortfalls in practice could place service users at risk. EVIDENCE: A tour was carried out of each unit. The corridors in all units were marked and need redecoration. There was evidence of some redecoration and refurbishment having taken place. Some carpets were due to be replaced and this had been planned for the end of November 2006. New furniture had also been purchased for the units. A redecoration and refurbishment programme Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 16 with timescales for completion was not complete, and this needs to be available and maintained up to date. The timescale for some of the refurbishment works set in the last inspection report had been exceeded and no contact had been made with CSCI. This was discussed with the Registered Manager at the time of inspection. On Beech unit the mirror in room 27 was cracked, the bathroom labelled room 38 the flooring had come away at the entrance, creating a trip hazard. The Registered Manager has since confirmed that all these areas have been addressed. On Larch unit the home was in the process of installing a new assisted bath, and the Registered Manager has confirmed this has now been completed. Each unit has assisted bath, shower and toilet facilities to meet the service users needs. One of the toilet facilities had been marked as ‘out of order’ due to the base being loose and this was being addressed. On Sycamore unit several items had been left in the bathrooms to include seat cushions, a strip of metal and a mattress. The need to ensure there is adequate storage for each unit was discussed. Toilet seats on the dementia units are now red in colour and the corridors brightly painted. In addition signage for bedrooms and baths, showers and toilets have been done in line with dementia care research. Moving & handling equipment was available on each unit to meet the needs of the service users. On the day of inspection some of the radiators were very hot and this was immediately brought to the attention of the maintenance man. It was stated that the home was awaiting a new part for one of the boilers and was currently having to adjust the boiler manually, and it appeared it had been put on a very high setting that could affect the radiator temperatures. Action was taken and assurance that the radiators are those specifically for low surface temperatures has since been received from the Registered Manager. The Estates Manager for BUPA has since carried out a visit to the home to review this situation, and has confirmed that the radiators are not low surface temperature radiators, but are oversize radiators with a thermostatically controlled hot water flow. A problem had occurred with the control panel which is being addressed. The hot pipes leading to the showers are not covered and get very hot when the shower is in use. Staff are always present to assist service users when showering. The need to carry out a risk assessment and take appropriate action to address this was discussed with the Registered Manager. Staff had received training in infection control. Protective clothing to include gloves and aprons was available on each unit. On Willow unit a container of cleaning fluid was found in one bathroom, and on Sycamore unit a marked hoist sling was found in one bathroom. These issues were brought to the attention of the registered nurse in charge of each unit. The laundry room was clean and tidy, with a good system in place for processing the laundry to minimise the risk of infection. There are 3 industrial washing machines with disinfection programmes available. There are 2 industrial tumble dryers. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 17 Although it was clean, some odours were noted on Beech unit and the Registered Manager was aware of this. Arrangements to replace some carpets in the near future are in place, plus daily cleaning routines to manage the ongoing problem of continence issues is also in place. The other three units were clean and smelled fresh. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the service users can be met at all times. Systems for vetting and recruitment practices are robust and protect service users. There is a comprehensive ongoing training programme, providing staff with the skills to meet the needs of service users, to include specialist care needs. EVIDENCE: At the time of inspection the units were appropriately staffed to meet the needs of the service users. Planned duty rosters were available for each unit and the Registered Manager stated that dependency levels are kept under review. Staffing had been increased on Beech unit to address the high care needs of one service user. 46 staff are qualified to NVQ level 2 or above, and this is well over 50 of the care staff. The home has a training programme in place and this evidenced frequent ongoing training in topics relevant to the needs of the service users. Training records were available and these, along with staff comments, confirmed that there is a comprehensive training programme in place. Staff employment records were sampled and those viewed contained the information required by the Care Homes Regulations 2001. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 19 BUPA have a comprehensive induction and foundation programme in place. Staff spoken with confirmed that they had undergone this training on commencing work at the home. Records viewed also confirmed this. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home and does so in an open manner, thus supporting staff, service users and visitors. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Service users monies are well managed and securely stored. Staff receive supervision, thus promoting communication and review of practice. Systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse with several years experience of managing care homes for older people. She has completed the Registered Managers Award, NVQ level 4. The Registered Manager has also Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 21 completed a post-graduate training module in the care of service users with dementia. The Registered Manager has an open and proactive approach to managing the home, and staff spoken with said that the Registered Manager and Deputy Manager are approachable and supportive. Regulation 26 visits on behalf of the Responsible Individual take place, with reports being formulated and copied to CSCI. Customer Satisfaction Questionnaires had been completed and an independent company collates the results. The need to ensure that the results are made available was discussed with the Registered Manager. The home also undertakes an annual self-audit, a weekly medication audit, monthly wound care, care plan and accident audits. Where shortfalls are identified an action plan is formulated to address this. There was evidence of regular unit staff, heads of department, service user and representative meetings taking place, and minutes of each meeting were available for inspection. An annual operating business plan was available and viewed by one Inspector. Six service users personal monies are managed by the home. Records viewed were up to date and receipts were available. Monthly reconciliations take place and the records viewed detailed interest being paid to individuals. Staff supervision records were sampled. These were up to date and had been signed by the supervisor and the supervisee. The records evidenced that care issues plus training and development needs are discussed. Staff spoken with confirmed that they receive regular supervision. Servicing and maintenance records were sampled and all viewed were up to date. Fire drill records viewed indicated that both night and day staff receive regular fire drill training. Training records provided with the pre-inspection questionnaire detailed that all staff had received health & safety training to include moving & handling, fire safety, First Aid, Infection Control, COSHH and food hygiene. Regular hot water temperature checks were being carried out and recorded, with evidence of remedial action being taken where any problems had been identified. The maintenance man has a copy of each service users bedrail assessment and ensures these are correctly maintained. Risk assessments for equipment and safe working practices had been carried out and updated in 2006. Overall health & safety was being well managed in the home. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 2 X X 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 23 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. 2. Standard OP8 OP8 Regulation 17(1)(a) 17(1)(a) Requirement Wound care records must be accurate and kept up to date. Where input from healthcare professionals is identified as required, this must be promptly actioned by the home. That the home and the pharmacist develop systems to ensure that when a dosage change occurs the contents of the Nomad are immediately corrected and maintained for the rest of the cycle. Where service users require a soft diet, an appropriate, appetising meal must be provided. The redecoration and refurbishment programme must be up to date and contain timescales for completion. Where timescales are exceeded, a clear explanation must be available. Any repairs must be promptly identified and addressed. There must be adequate storage facilities in the home. The home must confirm that all DS0000010951.V317791.R01.S.doc Timescale for action 17/11/06 17/11/06 3. OP9 13(2) 14/11/06 4. OP15 16(2)(i) 17/11/06 5. OP19 23(2)(b) (d) 01/12/06 6. 7. 8. OP19 OP22 OP25 23(2)(b) 23(2)(l) 13(4) 17/11/06 17/11/06 01/12/06 Page 24 Manor Court Nursing Home Version 5.2 9. OP26 13(2) the radiators in service user areas have controlled surface temperatures. Appropriate action, for example the fitting of guards, must be taken for any radiators that do not meet this requirement. Infection control and COSHH procedures must be fully adhered to. 06/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations That all currently prescribed medicines included those which may be required for palliative care are listed on the MAR. Manor Court Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Nursing Home DS0000010951.V317791.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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