Inspection on 14/02/07 for Manor House

This inspection was carried out on 14th 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 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 House 08/12/05

Manor House 28/07/05

Manor House 17/01/05

Manor House 22/06/04

Manor House 28/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Manor House 1 Amblecote Avenue Kingstanding Birmingham West Midlands B44 9AL Lead Inspector Jill Brown Unannounced Inspection 14th February 2007 08.35a 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 House DS0000016775.V330470.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 House DS0000016775.V330470.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor House Address 1 Amblecote Avenue Kingstanding Birmingham West Midlands B44 9AL 0121 360 0680 0121 325 1511 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) Servite Houses Tracey Tomlins Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: The Manor House is situated in a quiet residential area of Kingstanding in a modern purpose built building. It has access to buses within about 5-10 minutes walking distance and is accessible to the shopping area of Kingstanding itself. Servite Housing owns the home: one of two such homes in the city of Birmingham. It has accommodation for 35 older people set out in 35 single bed sitting rooms. These rooms also have a kitchenette area and ensuite facilities. The home has communal areas of a lounge /dining room, a separate conservatory, and a hair dressing room. The home has assisted bathing facilities on both of its two floors. The upper floor can be accessed by a passenger lift if needed. There is a level access entry to the front of the building and to the rear garden area. There are parking spaces available at the front of the building. The home currently charges between £368.00 and £408.37 per week. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited the home unannounced on a day in February. A key inspection was undertaken that looked at most of the standards that the home is assessed on. This took approximately 9 hours. During this time the inspector spoke to 5 residents and observed several interactions between staff and residents. Several resident records were looked including 2 resident care files in depth and further 2 in part, medication administration records, the personal allowance accounts and daily reports for a number of these residents were looked at. Staff files, staff and resident meetings records, complaints records and number of procedures were also looked at. Parts of the home were looked at including a number of resident bedrooms, the main lounge and some communal bathing facilities. The inspector received 3 comment cards from residents or their representatives. Two concerns had been raised with the Commission since the last inspection in December 2005. One was about the discharge of a resident from hospital. This was sent to the home to investigate. The home found that although there had been issues about the notice of the discharge from the hospital the home needed to improve their communications. The second anonymous concern was about the increasing need of a resident and whether the home could manage this. The manager of the home was assessing this at the time of the inspection and appeared to be taking all reasonable steps to assess whether the home could care for the person adequately with support from other agencies. The home advised the Commission of any accidents resulting in injury to residents and these were not excessive. What the service does well: Residents said that they were given information about the home and information was available for residents to look at. Residents had a contract with the home as well as a contract with social services if they were involved and this protects residents’ rights. The home collected good information about residents. As well as information about residents’ health conditions and difficulties information was collected about residents’ daily routines and preferences. Information collected also included how to communicate with residents, their history and hobbies and this assists staff in ensuring that residents can maintain parts of residents’ lives that are important to them. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 6 Residents have moving and handling assessments and the information on these are detailed enough to ensure that residents were moved safely and staff protected. Residents health care and personal hygiene needs were met. Residents were helped in a respectful way for example staff assisted residents that had short term memory problems in a way that didn’t show that the resident had forgotten or that they were being a nuisance. Daily reports of residents showed that if a health concern was raised that residents were referred to health professionals. Residents had their personal hygiene needs met and received help from staff. For example one resident said to another ‘I like your blouse’ the resident replied ‘the carer helped me choose it.’ Residents thought staff were ‘very good and helpful’ and the cleaners were ‘friendly. The home has good checks on the system of medication, coming into the home, storage, being given or taken and returned and this keeps residents well. Residents were able to make choices throughout their daily life. Choices included food, remaining in their flats or joining with other residents, times of getting up and going to bed, joining activities and freedom of movement around the home. Arrangements for the provision of food were good. Residents were able to have meals in the flats or in the communal dining area. The tables were set well and provided café style menus for residents to make their choice of meal. There were choices available at every meal. Residents were given extra food if they said they were hungry outside of meal times. Residents had opportunity to comment on food at residents meetings. The menu showed that there were changes in response to this. Residents comments on food ranged from ‘Very Good’ to wanting a wider range of traditionally English food. The home showed that they had ways of collecting residents’ views and showed that they try and solve any concerns they raise. The home does not expect to always have good views expressed and sees that concerns raised can help the home to improve. Residents and comment cards received said that residents felt safe in the home. The home is designed in a way to give residents independence whilst supporting their physical difficulties. All flats have small kitchen areas, en suites and there are a number of different type assisted bathing and showering facilities. The home was fresh and clean during the inspection, residents reported that this was always the case. The home had robust recruitment procedures, induction of staff and had the majority of staff trained to the basic level of NVQ2 in care. These actions ensure that residents can be assured that all safety checks are done before Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 7 staff start work at the home and that there are staff competent to give the care. The home undertakes good general risk assessments of issues that involve staff such as risks of intruders in the building and so on. The home has quality assurance systems and this enables residents to have a voice about the home and helps planning for future improvements. Money held on behalf of residents was accounted for by a good system of accounting. The home had good maintenance and inspection records of services s to maintain fire safety and the building services and this protects the safety of residents. What has improved since the last inspection? What they could do better: Where a resident understands information such as contracts they should sign it rather than a relative. Care plans needed to be less repetitive, include areas of care such as mental health. Risk assessments of risks identified in the assessment must be included in the planning. These improvements would ensure that all staff know and can provide appropriate care for residents. Residents thought that the activities could be improved to include more trips out and more outside entertainment. Records of activities that are provided and food eaten needed improvement for the home to show that were meeting need in these areas fully. The response to problems of water affecting plasterwork in the communal lounge was slow. It did not show that the organisation had robust emergency processes that supported the manager of the home. Whilst the home is giving update training to staff there was identified gap in the numbers of staff that are qualified as work place first aiders. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 8 The home had a number of policies and procedures that had been written by an outside company that did not reflect the good practice in the home. The home must adapt procedures so they clearly show the home’s practice and reflect good practice guidelines. This was outstanding from a previous inspection. 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 House DS0000016775.V330470.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 House DS0000016775.V330470.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): 1,2,3, & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a good level of information to ensure that can make a choice about the home. Good information is collected about residents and this assists the home in making plans to meet residents’ need. The home had contracts showing the terms and conditions of residents stay wherever possible these should be signed by residents to show that these have been discussed with them. EVIDENCE: The home had appropriate information to give residents about the service they provide. The inspector did not look at the home’s statement of purpose or service user guide on this occasion however previously these contained the required information. Comment cards received from residents stated that they had enough information about the home before admission. A service user guide was seen in the lounge for residents to look at when they wished. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 11 Residents at the home had contracts with the organisation telling them of the terms and conditions of their stay. One resident had a contract signed by a relative but it was clear that the resident was managing their financial affairs and this resident should be given the opportunity to sign this contract. Comment cards said that residents had contracts with the organisation. The inspector looked at three residents care files and found a good level of information in them. Care files showed that residents have an assessment before being admitted into the home. One Comment card said that the manager had visited the resident at home to make the assessment. This assessment contained information about what the resident could do, what they needed help with, it detailed what aids the residents needed and health conditions they have. The home also collected information on the resident’s history and activities this was important as it helps retain resident’s preferred lifestyle. Information was also collected the best ways to communicate with residents and these details help to include residents in the day-to-day life of the home. Moving handling assessments were completed and details of how residents can be moved safely recorded. In one case this was accompanied by detailed instructions and photographs and copies of these details were found on the resident’s file and in the resident’s flat. Manor House DS0000016775.V330470.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 &10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided good personal and health care to residents and ensured that this was given in a respectful way. Medication administration was checked at all stages and this helped to maintain the health of residents. Clearer care plans would assist staff in maintaining a consistent, safe standard of care and ensure that care is given in the way that residents want. EVIDENCE: Care plans were repetitive and were not always clear enough to be a good working prompt for care staff. The care plans forms had little space to detail the care that needed to be given. Care plan forms had been changed numerous times by the organisation, a period of stability with forms would give the home chance to ensure that these were completed more thoroughly. Where possible care plans were signed by the resident to show that the plans had been discussed with them and this was good practice. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 13 A number of residents have mental health issues that result in low mood or becoming unwell. The home weren’t recording in the care plan the signs that these residents display when becoming unwell so this can be identified quickly and appropriate health consultations sought. A number of risk assessments were not always completed where evidence of risks were recorded in the assessment and elsewhere in the plan. The home made good efforts to ensure the health needs of residents were met. Daily records showed that where residents have health concerns staff recorded these and action was taken to contact appropriate health professionals. One record showed a concern about a skin condition and the GP was contacted a prescription received and the cream made available within 24 hours. Daily records were appropriately used to pass information between staff to look at particular aspects of care however care records did not indicate where there was an increase in frequency of care given or the length of time and this was needed to ensure that all residents’ care can be managed. Resident received appointments with other health professionals such as chiropodist, community psychiatric nurses and so on. Residents were observed at various times throughout the day. Residents’ personal hygiene attended to and residents were given assistance where needed. One resident said to another ‘I like your blouse’ the resident replied ‘the carer helped me choose it.’ The hairdresser was available twice per week. The home notifies the Commission of any accidents ad incidents in the home as they happen. The weight records looked at showed that where needed residents weights were increasing and this assists residents keep well. The home had a good medication administration system. The inspector looked at 2 residents’ medication administration records (MAR), the homely medication, self-administration record and details of how medication kept in flats was recorded. The home copies the prescription so the MAR can be checked against it and so the medication received from the pharmacist can also be checked this was good practice. The medication found in the record matched the medication found in the cabinets. The home had systems in place to check the number of tablets where residents administer their own medication. It is recommended that is kept separate from the system of checking where medication is kept in resident flats to ensure that a check of the resident’s ability to administer is clearer. The home manager ensures that audits of staff competence were undertaken and that staff practice when administering medication was observed on occasions and this was commended. A member of staff undertaking a drug round on the day of the Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 14 inspection was knowledgeable of where drugs were kept and what specific drugs were for. The home managed medication flexibly one resident that managed their own medication came to the office to have their eye drops put in as they found that difficult and they were helped appropriately. Small improvements to practice would improve practice further. One resident record sampled did not have a photograph with the MAR and this is recommended as an extra check. The home was not recording the maximum minimum and current temperature of the fridge and this is recommended to ensure the medication remains within its product licence. The staff showed respect to residents and responded well to their difficulties. Residents that had short-term memory loss were attended to sensitively and well. One resident that requested help on several occasions was given that help in a way that did not indicate that they had made the request before and this was commended. One resident said it was difficult not being able to remember and it could make them nasty but thought staff would help if they were in trouble. Another resident thought it was a good decision to come into the home. Staff were seen knocking on residents’ doors before entering. Staff were seen acknowledging residents as they pass and asking about their day and this showed that the staff respect that this is the residents home. Resident comment cards said ‘ very good helpful staff’ and ‘ cleaners work everyday and are a friendly group of ladies.’ Manor House DS0000016775.V330470.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst the home arranges activities residents would welcome more outside activities and entertainers. The arrangements for residents to make choices in their life and for food were good and these enhance residents’ lives. There were no undue restrictions on visitors to the home. Better records of food eaten and activities undertaken would enable the home to show progress in these areas. EVIDENCE: The arrangements for activities varied. The Commission received an activities plan for March, which did not describe the activities to take place routinely except for the knitting circle, bingo and progressive mobility. It was clear that a number of residents had enjoyed being part of games such as scrabble, bingo and dominoes had the ability to join in. A new resident said that they had been playing dominoes on the day of the inspection and that they had Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 16 joined the knitting club. Residents were teaching one staff member how to knit.. The care staff were expected to record when they spend time with individual residents but this was not always completed. The home had taken a large number of the residents to Twycross zoo since the last inspection. Comment cards received asked for more trips and more entertainers. Relatives were included in the planning and on occasion the provision of care and this was commended. There were no undue restrictions on visiting the home. The home had just set up a call alarm for the front door to ensure that staff were aware when visitors were trying to access the building and the inspector found access to the building easier than on previous occasions. Residents were able to make choices. Residents had freedom of movement around the home and able to return to their flats as they wished. Care plans had details of residents preferred times of getting up and going to bed. Residents sign care plans where they were able. The home advises residents to bring what furniture they want into the home, as long it is safe to do so and the home supplies furniture only if residents do not have any to bring. This gives each flat an individual feel and helps residents retain their memories prior to coming into the home. The home had good arrangements for food. The home supplied the Commission with four weeks menu. The range of food on the menus was good. The menus showed that residents had a range of breakfast available daily of cereals, toast, prunes boiled eggs, and twice a week a full cooked breakfast was available. Residents had a choice of at least two cooked meals at lunchtime and a choice of pudding. At teatime soup, a cooked snack or sandwiches were available with cake and so on. Residents said ‘I like the food although some are a bit strange to my tastes, I like my vegetables cooked longer and more greens, but its probably better for me not to have them cooked so long.’ ‘Everything is good here. Food is lovely. Just look at those sandwiches.’ Comment cards ranged from ‘Very Good’ to wanting a wider range of more traditionally English food. Residents can have food at anytime, a resident during the inspection had forgotten they had their meal and lunchtime and said they were hungry arrangements were immediately made for the resident to be given a snack. A number of residents have their meals in their rooms. The inspector saw residents having tea and sat down with some of them. The tables were nicely set with teapots and milk jugs and so on. The tables also had café style menus with food of the day on and this was commended. Residents that had sandwiches had the choice of white or brown bread. The home were not recording how much individual residents eat and this is important as it needs to be looked at with their weight to ensure that residents remain healthy. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 17 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 had a responsible attitude to concerns and complaints and strives to continually improve the service provided for residents. Residents were protected from abuse and the follows the Birmingham Multiagency guidelines. EVIDENCE: The home demonstrated an openness in how it managed complaints and consults with residents to try to improve the service. The Commission received a concern about the discharge of a resident from hospital and this was sent back to the home to investigate. The home looked at their processes and whilst not being given much notice by the hospital found that there were areas of the homes’ communication that could be improved. A concern was raised about the amount of help a resident needed, in discussion the manager was aware of the difficulties and was taking steps to assess the amount of care needed and the difficulties in providing good care and whether these could be overcome to enable the resident to remain. The inspector was assured that this was not impacting on the care of other residents. The residents spoken to and comment cards received knew who to ask for help if they were worried and said they felt safe in the home. The home has Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 18 residents meetings and this was where residents’ suggestions for improvement were recorded. In the last meeting residents thought the food was not always hot enough, they wanted the craft days to continue, thought that a darts night would be a good idea and that the smokers should have an outside shelter. This input from residents was welcomed as it helped the home know where improvements were needed. As a result from a previous residents meeting the home’s newsletter is carrying a picture and information some staff on future editions so residents know the names of and roles of staff in the home. The home had two thank you cards on display that they had received recently. The home has a clear process of managing complaints but this is not reflected in their new complaints policy and the homes adult protection procedure does not reflect the multi-agency guidelines that the home uses. (See standard 37). The majority of the home’s staff had an NVQ 2 in care that contains a module on adult protection Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 19 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): 19,21,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean, fresh, and comfortable place for residents to live. The design of the building meets the needs of residents with physical disabilities. EVIDENCE: The home was clean and fresh at the time of the inspection and comment cards received suggested that this was always the case. The home was designed for older people. It offers a good environment with individual flats that allow residents a degree of independence. The home is kept in good order and there is a handy man to undertake day- to- day repairs. The home had wheelchair access throughout with level access from the street, passenger lift and accessible toilets and bathrooms. Residents that wished had keys to their front door and this was recorded in their care file. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 20 Following poor weather the home had some evidence of the communal lounge area of the home not being weather proof and arrangements were made to assure the safety of residents from affected plasterwork by the manager. There was a delay in assessing the extent of the problem and the inspector was advised that the manager was not aware of when a full repair would be completed. Subsequent to the inspection a temporary repair has been made and the inspector must be advised of when permanent repairs will be completed. The delay in assessment of this problem and some difficulty in emergency contacts needed to be improved. The four residents bedrooms seen were well furnished, clean and met the needs of the individual residents. A number of communal bathrooms were seen one of which has a new assisted bath, which the manager stated a number of residents prefer. All bathrooms had appropriate hand wash and drying facilities to prevent the spread of infections. The home had now employed a laundress. The homes infection control procedure does not reflect the good practice maintained in the home. (see standard 37) Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has the level of staff needed however further progress was needed to ensure vacant hours were recruited to, to provide consistency for residents. The home had good level of staff qualified to a basic NVQ 2 in care level. The home’s recruitment procedures were robust and this protected residents. Staff received training to do their jobs however the home needed to be assured they had enough staff qualified in first aid to give cover in the building to deal with emergencies. EVIDENCE: The home’s staffing level has been met since the last inspection however staff have left and this has meant that staff vacancies were covered by relief and agency staff. The home ensured that agency staff used were known to the home. The home had at least one early and one late senior member of staff on duty every day in addition to the manager hours, 5 care staff in the morning, 4 staff in the afternoon and 2 night care staff. The home has the services of a housekeeper each day and laundry staff 5 days a week and separate kitchen staff. The level of staff was maintained however occasional pressures due to deterioration in residents’ conditions needed to be accounted for. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 22 The home has 59 of its care staff with a NVQ2 in care or above and this figure is about the same when the relief staff were considered and this meets the standard. The inspector looked at two more recent staff files and found that the home was undertaking robust recruitment procedures with potential staff. The home had evidence of an application form, checks with the Criminal Records Bureau were in place before starting work and there were two references one of which was from a previous employer. The organisation ensured that a health declaration is signed before starting work and in one case this had yet to come back from the central office. The home looked for reasons for gaps in employment. The home also looked for declarations of interest to be signed. The home undertakes induction with new staff. The home had detailed general risk assessments for staff to cover potential areas of risk such as non-authorised access to the building and visiting potential residents homes and this was good practice. Staff in the home were undertaking training this week on Moving and Handling, basic first aid and food hygiene. The home managers were going on train the trainer’s course for moving and handling in an effort to keep the staff trained in moving and handling. The homes training matrix was on display in the manager’s office and this showed that most of the staff were trained in most courses appropriately the manager needed to be assured that there was always someone in the building who was trained in first aid. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 23 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): 31,32,33,35,37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed and run to the benefit of residents. The home has quality assurance systems and this enables residents to have a voice about the home and helps planning for future improvements. Money held on behalf of residents was accounted for by a good system of accounting. Improvements were needed to ensure that policies and procedures reflected the good practice in the home. The home had good maintenance and inspection records of services s to maintain fire safety and the building services and this protects the safety of residents. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager of the home has worked in residential care for older people for a number of years and has a NVQ level 3 in care. She is currently completing her NVQ4 in Management and Registered Managers Award. The inspector was informed that there had been some delays with this course and the college and the manager expected to complete soon. The manager showed leadership and ensured that appropriate procedures were carried through if there were any shortfalls in the homes or staffs performance. The home had several methods of checking the quality of the service the home offered. The Commissions comment forms were displayed routinely in the reception area of the home. There were regular residents meetings, some staff meetings and service managers from the organisation visited. The home had an independent quality assurance assessment and a health and safety audit. The home scored well in the quality assurance assessment. The organisation undertakes audits of the home’s performance in several areas such as the provision of activities. Residents’ money was appropriately accounted for with robust systems of monitoring. The inspector looked at 3 residents money records and cash held. The home keeps a float of money up to £50 to assist residents and their representatives manage services such as hairdressing, chiropody and to help those residents that wish to play bingo or go out. All the records matched the amount held. There were clear receipts for any money spent and the home had good systems of checking that the money and the accounting were correct. Residents that wanted to manage their own money were able to do so. The provider has been developing a number of policies and procedures with an organisation. These policies and procedures need to be read and audited to ensure they meet the home’s practice and any local guidelines. For example the new adult protection procedure does not clearly state that social services must be contacted as they are the lead agency for adult protection and the complaints procedure had positive and negative complaint procedures and referred to a further complaint procedure that was not available. The Laundry procedure outlined a process that was not current in the home and did not ensure good infection control. This remained outstanding from the previous inspection. The home had the appropriate maintenance and inspection documents and certificates to ensure that the home was safe. For example for fire safety, the home was aware of the issue of new guidelines about fire safety and they were expecting training on this in next few weeks. The home had a fire risk assessment although this was due for review. The home showed that they responded to information following drills such as checking the position of door guards following an alarm test. Emergency lighting and fire equipment was Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 25 serviced and checked routinely. There were fire drills. The home had undertaken all the actions required by the West Midlands Fire Service in their last inspection. Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 26 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 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x 3 X 2 3 Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 27 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. 2. Standard OP2 OP7 Regulation 5(1)(c) 15(1) Requirement Where a resident understands a contract they should be the person signing it. The home must ensure that care plans show how needs are to be met. (This remains outstanding since 28/02/05 and partly met 31/03/06) All risks identified in the assessment must have a risk assessment and actions identified to minimise the risk. The home must ensure that they keep records of activities undertaken. The home must show how activities respond to individual social needs. The home must keep a record of the food that residents eat to ensure that the impact on residents health can be monitored. Timescale for action 30/04/07 30/04/07 3. OP12 16(2)(n) 30/04/07 4. OP15 Sch 4 13 30/04/07 Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 28 5. OP19 23(2)(b) The registered provider must ensure that a list of emergency contacts is available for the manager and a copy of this must be sent to the Commission. The registered provider must advise the Commission when permanent repairs are to be completed to prevent the ingress of water. The arrangements for the recruitment of permanent staff must continue. Timescale of 31/01/06 not met The home must ensure that the number of staff trained ensures that there is a workplace first aider at all times. The manager must complete the equivalent of NVQ4 in care and in Management. Copies of relevant certificates must be sent to the Commission. The home must review all the new policies and procedures to ensure that they reflect practice in the home and local agency guidelines. Policies looked at and needed revision were: Complaints Adult protection Laundry Timescale of 31/03/06 not met 31/03/07 6. op27 18(1)(a) 31/05/07 7. op30 13(4)(c) 30/04/07 8. OP31 10(2) 30/06/07 9. OP37 13(4)(c) 30/04/07 Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 29 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 It is recommended that the home separates the system of checks for residents that administer their own medication and those that only have their medication stored in their flat. It is recommended that a photograph of the resident is next to the relevant Medication Administration Record (MAR) in all cases. It is recommended that the home records the maximum minimum and current temperatures for the medicinal fridge to ensure medication are kept within its product licence. 2. 3. OP9 OP9 Manor House DS0000016775.V330470.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 House DS0000016775.V330470.R01.S.doc Version 5.2 Page 31 - 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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