Inspection on 02/10/06 for Manor Farm Care Home

This inspection was carried out on 2nd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Farm Care Home 29/04/08

Manor Farm Care Home 15/10/07

Manor Farm Care Home 07/11/05

Manor Farm Care Home 01/08/05

Manor Farm Care Home 21/12/04

Manor Farm Care Home 24/05/04

Manor Farm Care Home 02/12/03

Manor Farm Care Home 16/09/03

Manor Farm Care Home 29/08/02

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

CARE HOMES FOR OLDER PEOPLE Manor Farm Care Home 211-219 High Street South East Ham London E6 3PD Lead Inspector Nurcan Culleton Unannounced Inspection 2nd October 2006 10:00 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 Farm Care Home DS0000007361.V307505.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 Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Farm Care Home Address 211-219 High Street South East Ham London E6 3PD 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) 020 8548 8686 020 8548 9929 Trees Park (East Ham) Limited Jacqueline Bridget Philomena Connolly Care Home 81 Category(ies) of Dementia - over 65 years of age (58), Old age, registration, with number not falling within any other category (23) of places Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 32 BEDS ELDERLY MENTALLY ILL PERSON - NURSING 26 ELDERLY FRAIL NURSING 23 ELDERLY FRAIL - RESIDENTIAL MINIMUM STAFFING NOTICE Date of last inspection 7th November 2005 Brief Description of the Service: Manor Farm is one of a group of care homes run by Trees Park (East Ham) Ltd. It is a purpose built dual registered residential and nursing home. It is registered to take 81 elderly service users over the age of 65 years with mental health needs; residential and nursing care needs. The home is divided into three units. The top floor is residential while the ground and first floor units are for service users with nursing needs. The accommodation is spacious, comfortable and well furnished and there are front and back gardens. There are single and double rooms, all with en-suite facilities. The home is situated in East Ham, close to shops and local amenities with good access by public transport. Parking facilities are available in the front of the building. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 2nd October 2006. The Registered Manager was present to assist the inspector. The Regional Manager for London was present at the beginning of the inspection. This report summarises the outcome of the inspection following interviews with the Registered Manager and three service users, three staff members and a relative. The inspector also toured the premises and examined the quality of records and documents related to service users and staff including service users and staff files. The last inspection took place on 07th November 2005. This inspection also reviewed the four requirements given at the last inspection, examining whether progress has been made since then. There were seventy-nine service users residing in the home at the time of the inspection and two vacancies. What the service does well: What has improved since the last inspection? What they could do better: A significant increase of requirements have been given, eleven in all, including one restated requirement, covering a range of areas identified for improvement. These are concentrated in five main areas: Care plans, assessments, medication, the environment and improvement planning and Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 6 review of the service (quality assurance). Previous inspections identified that these were areas requiring improvement. Whilst improvements had been made at the last inspection, this inspection has found that standards of quality in these areas must continue to improve and must consistently be maintained in order to safeguard the health, safety and welfare of service users. 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 Farm Care Home DS0000007361.V307505.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 Farm Care Home DS0000007361.V307505.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, 3, 4, 5, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All service users are provided with information about the home, though the format of this information needs to improve. Some improvements are required to some of the specialist assessments in order to ensure that all service users’ needs are met. EVIDENCE: The home’s Statement of Purpose and Service Users Guide has been combined into one document and contains all elements required by regulation. However the combined document is excessively lengthy and for this reason is not in a format which is easily accessible and suitable to service users. The service users and relative who spoke to the inspector also said the document was difficult to read. It is recommended that the two documents are separated in order to be more user friendly to provide information in a suitable format to prospective and existing service users. The home assesses service users’ needs Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 9 prior to their admission through a pre-admission assessment after receiving assessments from the Local Authority. Service users’ previously examined assessments were satisfactory, covering a range of service users’ needs to form a basis for the development of the homes’ individual care plans. The assessments used by the home need to improve as follows: Numerical scoring systems must be accurately calculated in assessments. The inspector observed in a nutritional risk assessment that a score was calculated at 23 rather than 20 as it should have been. The Dependency Profile, mobility scoring was recorded as 3, ‘may need assistance.’ However the service users’ care plan stated that the service user needed two people for transferring, though they were able to walk small distances with a zimmer frame. A staff member also used 0 as a coded number, however this score was not available as the scores ranged from 1-5. Service users in previous inspections had confirmed that they or their relatives were able to visit the home. The home does not provide intermediate care. The home has demonstrated that, whilst improvements are still required, it is generally able to meet service users’ needs Manor Farm Care Home DS0000007361.V307505.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, 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ files are in order and set out their health, personal and social care needs. Service users’ health needs are met. Service users’ privacy and dignity are upheld. Service users’ care plans and identification of their needs must improve. Some requirements are given concerning medication. EVIDENCE: The inspector examined three service user files. All files consistently contained the same range of assessments and documentation. At the last inspection, the inspector observed that there had been improvement in the recording of care plans, assessments and risk assessments. Further progress is still required to develop and maintain a good standard as shortfalls were identified as follows: Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 11 As identified in the previous inspection report, service users’ care plans are completed with reference to why a service users’ need develops rather than specifying what the need actually is. For example, one care plan stated, ‘Problem : pressure sore, Need: due to immobility’, rather than outlining the need itself. This means that service users’ needs and actions linked with needs are not always clearly identified in their care plans. Another service users’ care plan stated ‘ Problem: restricted mobility, Need: due to fracture of the hip’ rather than, for example, unable to transfer independently or walk long distances without support. The writing of some care plans was hard to read and must be more legible. All needs identified in assessments, short- term and long- term care plans must be consistent and clearly identified: The short- term care plan must and long term care plan of one service user contained inconsistent information about their need. The short- term care plan recorded that the service user needed two people for assistance with walking. The long- term care plan stated that the service user needed ‘assistance with transferring’ and made no reference to any other assistance with walking. The moving and handling assessment of one service user stated they needed the assistance of one staff for a shower. This was not identified in the long term care plan. Care needs identified must be specific and not generalised. One service users’ short- term care plan noted that she required assistance with her ‘daily routine.’ This is too vague and fails to identify her needs. One service user scored a 4 in the Dependency Profile (moderate assistance needed) for a pressure ulcer however no pressure sore assessment was in the file. Where needs are identified which require an individual assessment of that need, the assessment must be available in the file. Care plans were however signed by the service users or their representatives. Long term care plans are reviewed and signed every six months and shortterm care plans are reviewed and signed monthly. Medication administration records were checked and deemed to be accurate at the time of inspection. However whilst touring the premises, the inspector observed the following shortfalls which require actions as outlined below to ensure safe medication practises: Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 12 Medication found loose in service users’ bathrooms, including creams, must be stored in cabinets for safe storage. Prescribed medication, such as E45 creams, must not be transferred for use to other service users once the cream is no longer required by the service user originally prescribed for. All disused medicines must be returned to the pharmacist. A range of other assessments were seen in files, recording service users’ other health and personal care needs and a social activity chart. Most other records were available in service users’ files, such as interventions from the G.P and other health professionals; daily observation notes are recorded from day and night staff. It was evident in documents, including short- term care plans, that service users’ individual preferences regarding their care were identified, with a view to maintaining service users’ privacy and dignity, ie, ‘assist x with her choice of clothes to maintain her self-image. Also ensure she maintains her feeling of pride.’ The inspector also observed that service users were sensitively cared for in the dining rooms and lounges by caring staff, for example, seating service users in their preferred seats. Service users’ death/dying wishes are recorded in the front of their files. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to engage in a variety of social activities. Service users are offered choices, encouraged to exercise control and maintain their independence to their ability wherever possible. Service users are generally satisfied with and consulted about their meals. EVIDENCE: Service users’ religious, cultural and language needs are identified in the front of their files. The menu in the home takes into account any preferences expressed by service users, including Chinese food for the benefit of two Chinese service users. One of the Chinese service users goes to a Chinese day centre assisted by Dial-A-Ride. A priest regularly visits for other Christian service users. The Registered Manager informed there were no other expressed religious or cultural needs expressed by the service users. The inspector observed that service users’ notice boards were difficult to read with overlapping paper and information, some in small writing which may be Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 14 difficult for some service users with poor vision to read. The inspector recommends that social activities notices are better displayed for service users. The inspector observed a wholesome, balanced meal being offered to service users at the time of inspection. The menu examined offered varied and nutritious meals. Service users are consulted about their food preferences the day beforehand. Service users are able to choose meals not on the menu with a variety of alternative foods available, as observed with one service user who chose to have a fried egg instead of salmon or lamb. Food was also served according to individual needs, for example food from the day’s menu was pureed for some service users. Service users spoken to informed they liked the meals. Coded social activities were recorded in service users’ activities charts in their files. The opportunity for increased social and community activities for those service users’ wishing to go out is now possible with a newly purchased minibus. Service users spoken to informed the inspector that they were aware of the social activities within the home, though chose sometimes not to engage. There is a full-time Activities Co-ordinator, formerly a care worker in the home, who undertakes activities on each floor. Activities are displayed on the wall on the walls. They include singing, dancing, crafts, bingo and trips out. The Activities Co-ordinator will be undertaking training to further develop her in her role. Individual service users’ needs and preferences are accommodated as far as possible. For example, some service users are assisted to go out for personal shopping at their request. Service users are able to do their own laundry should they prefer to do so. Service users’ own tastes are reflected in their rooms. Family contact is encouraged. The inspector observed relatives visiting the home and interviewed one relative who was generally very pleased with the home. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 15 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, 15, 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 evidenced that it listens and acts upon the views of service users and their relatives. Service users benefit from staff who are aware of adult protection issues. Service users’ legal rights are protected. EVIDENCE: There were seven complaints recorded in the home since the last inspection in November 2005. These were investigated appropriately, actions taken were appropriate and outcomes noted. The CSCI received two complaints during this time, which were examined as part of this inspection. These are addressed in the next two sections. The relative spoken to informed the inspector that the manager promptly dealt with any issues she raised and was satisfied with the outcome on those occasions. The inspector is satisfied with the complaints procedure in place. There have been no adult protection issues raised since the last inspection. Staff are aware of adult protection issues and training is available. Service users are enabled to vote and are given their own mail where possible. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 16 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, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in comfortable, generally well-maintained surroundings. There are sufficient facilities in the home and the home meets its stated aims and objectives. The appearance of the bathrooms must improve. Some requirements are given regarding the environment. EVIDENCE: The inspection covering these standards took into account two respective complaints, one from a relative and one from a social worker made prior to this inspection. They included various concerns: washing up area being unhygienic; small dining room for service users’ needs; kitchen equipment; presence of mice; lack of hoists; one service users’ bedroom. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 17 The inspector toured the premises. The house was generally clean, well maintained, well decorated and free from odour. Bedrooms contained personal effects such as pictures and photographs and other personal items. There were sufficient bathroom facilities in the home. There was evidence of several hoists in working order around the premises and aids and adaptations are in place. There are comfortable lounges for socialising and activities on each floor. The inspector observed service users’ being assisted into their dining rooms for lunch. Whilst the rooms are small, they are sufficient to meet the needs of the service users’ even with their wheelchairs. The inspector saw no evidence of difficulty or distress caused to service users by being in a small room, in respect of a complaint received by a relative prior to the inspection. The Registered Manager informed that not all service users choose to come into the dining rooms to eat. The inspector was satisfied with the kitchen equipment and there were sufficient utensils available. The Registered Manager acknowledged that there was a problem with mice in the home, however records were shown of a contract with Rentokil and regular call outs with them. There was concern of blood on the door of one service user reported to the CSCI. The Registered Manager advised that this was a stain from the varnish on the door rather than blood and arranged for it to be sanded down. The inspector however observed the following shortfalls where action is required: The floor of the washing up area on the second floor was sticky and unhygienic. It is a requirement that a high standard of hygiene is maintained in all areas of the home. The toaster in the dining room of the first floor needs more thorough cleaning. The bathrooms were white, bare, sterile and unsightly. They contained hoists and trolleys with untidy bedroom sheets, as well as incontinence pads and other clinical items which were open to view. The appearance of the bathrooms were in contrast to the objective in National Minimum Standards of ensuring that all areas occupied by service users’ in the home are in keeping with a homely living environment. The bathrooms would benefit from cabinets to store personal/clinical items, such as incontinence pads, away from view, improved storage for laundered sheets, screening for the hoists and decorative items for the walls to create a more homely atmosphere. The Registered Manager must investigate alternative storage for hoists kept in bathrooms or to provide screening for the hoists. The shower room on the first floor was water logged and needs to be repaired. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 18 Hoists stored in the room used interchangeably for service users and staff meetings must be stored elsewhere or have appropriate screening. Decoration is required to the wall on the first floor where the paper has torn. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 19 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. Service users benefit from skilled, competent and knowledgeable staff who receive regular training and supervision to support them to undertake their duties and responsibilities. A statement of mental health must be included in the statement of fitness. EVIDENCE: There are sufficient numbers of staff to service users in the home. On the ground floor there is one nurse and four carers to twenty- six service users. On the first floor there is one nurse and six carers to thirty- one service users. On the second floor there are three carers, including one senior, to twenty- two service users. The staff files examined contained all documents required by regulation, however the statement of fitness questionnaire, which is now available in files, must also include a statement on mental health. This is an outstanding requirement. The inspector discussed staffing issues following a complaint about staff pay, the poor English of some staff and the lack of training. The Registered Manager Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 20 informed that no staff is paid below the minimum wage. This was confirmed when the inspector saw contracts of employment and terms and conditions in their staff files and also by staff who were interviewed. There are currently ‘Adaptation Staff’ employed in the home, registered nurses in their own countries who are transferring to work in this country. They perform all the same tasks as RGNs under their supervision. They have passed English tests by the NMC prior to their appointment, however their accents may be strong. Staff confirmed that they received regular, good training and training certificates were available in staff files. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home which is managed by a person with experience in their field and who has demonstrated competence to lead this service. There is a positive ethos and management approach to the home. Service users’ health and safety is promoted and protected in the home. EVIDENCE: The Registered Manager has previous experience in management as a nurse and as a sister in a hospital prior to her employment in the home. She also has an NVQ Level 4 and further relevant professional qualifications. She has Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 22 demonstrated her capacity to take on board issues raised at previous inspections and has been pro-active in improving practises within the home. Staff and service users inform that the Registered Manager is approachable and responsive when approached. Policies and procedures are available in the home. Relatives are currently not attending meetings though they are still being arranged. The inspector advised for the need to improve the visibility of the dates for meetings in the entrance, and suggested a large notice board for greater impact. The Registered Manager is required to increase efforts to engage relatives and seek their views and the views of others on the quality of service provision, for example, with an additional comments book. The homes’ quality assurance system needs to improve. Currently there are questionnaires about service satisfaction for visitors, staff, relatives, service users and multi-disciplinary professionals in the entrance of the home. The inspector recommends that questionnaires include views on staff competence and whether service users’ needs are being met. The home currently does not record the outcome of its quality assurance monitoring. There is also no system of using the results of its self-monitoring for ongoing improvement planning of the service. Service provision must be reviewed and the views of service users and others must be taken into account when measuring the success of the service against the homes’ aims, objectives and Statement of Purpose. The inspector examined a sample of service users’ money and deemed the balance of monies available and balance recorded in their books to be correct at the time of inspection. Staff attend regular team meetings and receive regular supervision either from the Registered Manager or the seniors, and all staff receive annual appraisals. All health and safety certificates, gas, electricity, water were available. The home observes all health and safety and fire safety routine checks, such as water and food temperatures, fire alarm checks and drills. Maintenance checks and invoices were available for the home, including all equipment used by service users and the lifts. However the maintenance folder was overfull and whilst there are currently no concerns around health and safety, there is no system in place of monitoring when safety checks are due with contractors and of ensuring that maintenance checks are carried out. A more efficient monitoring system including an improved filing system of invoices, certificates and records is required. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 23 Manor Farm Care Home DS0000007361.V307505.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 2 x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 3 3 3 3 3 Manor Farm Care Home DS0000007361.V307505.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 OP3 Regulation 12, 14 Requirement Numerical scoring systems must be accurately calculated in assessments. All service users’ needs identified in assessments, short term and long term care plans must be consistently identified. Care needs identified must be specific and not generalised. Care plans must be legibly written. Service users’ needs, linked with the ‘problem identified’ column in their care plans, must be clearly specified. Medication found loose in service users’ bathrooms, including creams, must be stored in cabinets for safe storage. Prescribed medication, such as E45 creams, must not be transferred for use to other service users once the cream is no longer required by the service user originally prescribed for. All disused medicines must be Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 26 Timescale for action 30/12/06 OP7 2 OP7 12, 15 30/12/06 3 OP9 13(2) 30/12/06 4 OP19 16(2)(c) returned to the pharmacist. The Registered Manager must investigate alternative storage for hoists kept in bathrooms or to provide screening for the hoists. Hoists stored in the room used interchangeably for service users and staff meetings must be stored elsewhere or have appropriate screening. Bathrooms must improve in their appearance to create a more homely atmosphere, such as improved decoration or decorative items on the walls. More appropriate storage is required for laundered sheets, incontinence pads and personal/clinical items currently stored in the bathrooms, such as cabinets. The water logged shower room on the first floor must be repaired. Decoration is required to the wall on the first floor where it has been torn. The toaster in the dining room of the first floor needs more thorough cleaning. The floor around the washing up area on the second floor must be cleaned. The Registered Manager must ensure that a high standard of hygiene and cleanliness is maintained throughout the home. The Registered Manager must ensure that a statement of mental and physical fitness is available for all employees of the home. The timescale of 20/01/06 DS0000007361.V307505.R01.S.doc 30/12/06 5 6 7 8 OP19 OP24 OP26 OP26 13(4) 23 2(b) 23 2(c) 23 2(d) 30/12/06 30/12/06 07/11/06 07/11/06 9 OP29 17 (2) 30/12/06 Manor Farm Care Home Version 5.2 Page 27 10 OP33 24 has not been met. The Registered Manager is required to increase efforts to engage relatives to seek their views and the views of others on the service provision The Registered Manager must ensure that the results of the homes’ quality assurance monitoring is recorded. The Registered Manager must ensure that the results of its quality assurance findings are used in the continual improvement planning of the service. This must be based on the views of service users and others. The success of the service must be measured against the homes’ aims and objectives and Statement of Purpose. A more efficient system is required to identify when health and safety checks with contractors are due and of monitoring and ensuring that routine checks are carried out. 30/12/06 11 OP38 13(4), 23 (2) 30/12/06 Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 28 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 5 Refer to Standard OP1 OP12 OP33 OP33 OP33 Good Practice Recommendations It is recommended that the Statement of Purpose and Service Users Guide are separated in order to be more user friendly. The inspector recommends that social activities notices are better displayed for service users. It is recommended that quality assurance questionnaires include views on staff competence and whether service users’ needs are being met. The inspector recommends that a comments book is made available for relatives and others regarding the quality of service provision. The inspector recommends a large, free-standing notice board in the entrance to advertise forthcoming events such as relatives meetings. Manor Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Farm Care Home DS0000007361.V307505.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!