CARE HOMES FOR OLDER PEOPLE
Manor House 80 Huntingdon Road Upwood Huntingdon Cambridgeshire PE17 1QQ Lead Inspector
Lesley Richardson Unannounced Inspection 9th January 2008 10:30 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 DS0000024320.V358595.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 DS0000024320.V358595.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Manor House Address 80 Huntingdon Road Upwood Huntingdon Cambridgeshire PE17 1QQ 01487 814333 01487 710083 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) www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Manager post vacant Care Home 43 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (38), of places Physical disability (1), Physical disability over 65 years of age (38) Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. The number of nursing care places may not exceed 27 at any one time One named male under 65 years of age with physical disability for the duration of their residency. The number of places for OP and PD(E) may not exceed 38 for the duration of conditions number 2 and 4 The number of places for DE(E) may not exceed 4 at any one time The total number of people accommodated in the home may not at any one time exceed 43 1st February 2007 Date of last inspection Brief Description of the Service: Manor House is an adapted 19th Century domestic dwelling located in the small village of Upwood, about 3 miles from Ramsey. The building, that has served as a vicarage and later a surgical unit for overseas military, is arranged on two levels with well-maintained gardens to the front of the home. Parking is available to the front of the home. Accommodation is on two floors, with a lift to the first floor. The home is registered to provide accommodation care, including nursing care, for a maximum number of 42 service users over 65 years of age. Applications for minor variations of registration have been approved for 4 places for people over 65 years of age with dementia and for one named person under 65 years of age with a physical disability. Current fees range from £500 to £605. Additional costs include those for chiropody, hairdressing and newspapers. A copy of the inspection report is available on request at the home or via the CSCI website. Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
This was a key inspection of this service and it took place over 6½ hours as an unannounced visit to the premises. It was spent talking to the manager and staff working in the home, talking to people who live there and observing the interaction between them and the staff, and examining records and documents. Two requirements from the last inspection have not been met. There have been no further requirements and 1 recommendation made as a result of this inspection. Information obtained from the Annual Quality Assurance Assessment and from an ‘expert by experience’ was also used in this report. What the service does well:
The home provides care, including nursing care, and accommodation to up to 43 older people. People who live at the home say they like living there and comments include, “staff are 100 , very good”, “fine because I’m happy (here)”, “nice people not always saying do this do that” and “Love it here, beautiful”. An assessment is obtained before people go to live at the home to make sure staff there are able to care for them. Care plans are written to show staff how each person likes to be looked after. This information tells staff about the person as well as what they need to do to make sure the person is cared for properly. Each person is registered with a GP and they can see other health care professionals, such as dieticians, specialist nurses or opticians, if they need to. Staff are polite and respectful to people living at the home. They take their time and don’t hurry people. One visitor to the home commented that, “I feel that my Dad has been looked after very well. So well done to you all concerned”. The home has an open visiting policy; people are made welcome and can visit in private or in communal areas as they wish. Generally people who live at the home can choose how they live day to day. For example, when they get up and go to bed, what they wear and have to eat. Most people think the meals provided are good and there is a choice of main meal and snacks are available at other times if people are hungry. Not everyone thought they are able to choose to do things or were happy with the meals and this has been mentioned in the section ‘What they could do better’.
Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 6 Most of the home is a clean and pleasant place for people to live; it smells fresh and is nicely decorated. Again, there is one issue where improvement is needed and that is talked about in the section about what the home could do better. There is a complaints policy and procedure available around the home and most people know how to make a complaint, and who to talk to if they’re not happy about something. There have been only a few complaints made in the last year and most of these have been looked at in the correct time frame. Staff members have training in how to protect people from abuse. There have been no incidents reported to the local adult protection team. Recruitment checks are carried out before new staff start working at the home, which means the home knows if it’s safe to employ people and this keeps people living at the home safer. Staff members have training when they first start working at the home. This includes mandatory health and safety training like moving and handling, and fire awareness. Other training is given so that staff know how to properly care for people when they are coming to the end of their lives. Each year a survey is carried out by the home. This asks people who live there, their relatives, staff and other people who visit the home, such as doctors and nurses, what they think of the home and the care that is given. The last survey was carried out at the end of 2007 and the home is waiting for a report to be published so it can look at the things it needs to improve. Health and safety, and maintenance checks are carried out at required intervals on all mechanical and electrical systems and products in the home. This makes sure that things are in safe working order for people to use. What has improved since the last inspection? What they could do better: Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 7 Although two of the requirements about medication were met, a third one was not. Medication that is kept in people’s own rooms must be stored securely, so that it is safe. People who live at the home have their hair dressed in the main foyer area, just inside the glass front doors. This is not an appropriate place for people to sit and have their hair cut, or for other things, like trimming facial hair, to be done. Not everyone who has their hair cut in this area feels comfortable sitting in such an open, communal area. The second requirement that has not been met is about the size of the corridor in South Wing. This corridor is too narrow and equipment like hoists and stretchers cannot get to the rooms along there. The BUPA organisation has told us how it is planning to change the wing, but there is no firm date when the work is going to start. There are also no plans for moving people out of the corridor, so that work can start. We will be taking legal advice about whether the home should continue using the wing as there are health and safety, as well as dignity, risks to staff and residents. There are usually enough staff working at the home for people to get care and attention when they need it. But, there are busy times when there are not enough staff and people are kept waiting. For example, during lunch time when people need help to eat, some people were still eating their meals an hour and 10 minutes after sitting down. There is no permanent manager at the home. The deputy manager has been working in the acting manager position, but has also had to carry out other roles, as there is no administrator either. Managers of other BUPA homes are supporting the home. 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 DS0000024320.V358595.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. The home has adequate information about people before they live there. This means they are able to make a decision about whether the person can be properly cared for before moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager carries out assessments before people move into the home. Further assessments are obtained from health and social care teams and provide additional information so the home is able to say whether it has the staff with the skills and experience to properly care for someone moving in. 40 of people who returned surveys said they have a contract with the home and 50 said they received enough information before moving into the home. The home does not provide accommodation specifically for intermediate care or for rehabilitation purposes.
Manor House DS0000024320.V358595.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 and 10 Quality in this outcome area is adequate. Care is provided in a person centred way that makes sure people are able to say what they want and get it. Staff must continue to improve medication practice so that this is stored safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recently started using a new assessment and care planning system. Although all the information relevant to each person’s care has always been available in one folder, the new system divides care into broad sections. Care plans and associated risk assessments are kept in respective sections, which provides an easy guide to staff and makes it clear why some care has to be given in a particular way. Each person in the home has an individual folder with this information. Care plans are written in detail and as a story about the person, and give a sense of who the person is, what they are like and what they like and don’t like. For example, one person’s care plan includes information about her hearing aid,
Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 11 how high to turn it and the effect on her if she doesn’t wear it. Another person’s care plan shows the equipment that is needed for staff to safely transfer this person. This includes details about the sling and the footwear this person likes to wear. Plans written by one staff member gave so much information in a ‘story’ format that it was difficult sometimes to know exactly how to carry out particular tasks. There is a danger that things might be missed because there is so much information. Most plans are reviewed at least once a month and contain information about any changes that have occurred since the last review. This information isn’t always transferred to care plans due to the story style they are written in. It means that plans are not always up to date and staff must read through the monthly reviews to find out about changes. Risk assessments are completed and then reviewed at least every month. All of the people living at the home and relatives and visitors who returned surveys said they get the care and support they need, usually when they need it. Comments made by people at the home and their relatives were positive about the care they receive and about the care staff. These include, “pleased with the standard of nursing care & the amount of information provided by them” and, “I feel that my Dad has been looked after very well. So well done to you all concerned”. It is clear that staff know people’s needs and how they like to be cared for. One person’s relatives said staff are able to tell when she needs to go to the toilet by how she is behaving and that she likes to have her clothes put away before going to bed or she will get out of bed and put them away herself. People in the home have access to health care professionals and there was information in records seen to show referrals to dieticians, speech and language therapists, physiotherapists and other professionals are made. This information and advice is recorded and becomes part of the care plan for that person. Everyone returning surveys said they have access to medical advice and support when they need it. Medication administration records are completed correctly, with very few entries not signed or given a key code to indicate the reason the medication was not given. Two people continue to administer their own medications and there are risk assessments in their care records to show they are able to do this. Another person has a prescribed cream that is kept in her room and she said it is kept in a locked drawer. However, the cream was found on a shelf above the sink in this person’s room during the inspection and therefore was not stored safely. Staff members are polite, and they speak to people with respect. People said staff are nice, they usually do everything they need to look after them and they do things like knock on doors before going into the room. Relatives and visitors to the home also said the home gives the care that is expected and
Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 12 keeps them up to date with any issues that arise. However, when we started this inspection there were quite a few people having their hair done by the hairdresser. This was taking place in the foyer of the building just inside the main glass doors and people were sitting with their hair in rollers and under dryers or having their hair cut. One person said he felt uncomfortable having his hair cut in an area where people are walking through. Another person had her facial hair trimmed while sitting in the foyer. It does not respect people’s right to privacy or maintain their dignity to have this type of care carried out in communal areas of the home. Manor House DS0000024320.V358595.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 and 15 Quality in this outcome area is adequate. The available activities and access to the visitors and the local community provide positive experiences for people, although consideration should be given so that everyone at the home is able to make choices about how their days are spent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a new activities co-ordinator who is employed on a part time basis and has worked there since just before Christmas. The previous activities co-ordinator left the position some months before that. Half of the people at the home who returned surveys said there is nothing to do and no activities available for them to take part in. One person’s relatives said the activities co-ordinator used to help her take part in physical activities, which she enjoyed, but these were no longer available. They said this lack of physical stimulation and her poor hearing was making her less interested in things going on around her. The home has an open visiting policy and people visiting the home during the inspection said they are able to visit every day. Half of the visitors who
Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 14 returned surveys said the home helps their relative keep in touch with them and most people said they are kept informed of any issues that arise. People at the home said they can go to bed and get up when they want. They can choose their meals, wear what they want and they are able to choose what they do during the day, although there are limited activities available at present. 50 of visitors who returned surveys said the home supported people in living their lives as they choose to while living there. One person said this only happens sometimes. Everyone returning these surveys said the home meets diverse needs of people, such as cultural and religious needs. Two people, however, said they found they are not always provided with the opportunity to do things if they wish. For example, it is difficult for one person to go downstairs because she finds the seating uncomfortable and toilet facilities are not suitable. If this was provided, she would be able to decide whether she goes to the lounge room or not, rather than not being able to make the choice at all. The home has recently introduced a new meal planning system that offers people more choice and identifies foods that could be included in different diets, like those that are high fibre. There is also a ‘nite bites’ snack menu that gives people the choice of hot or cold snacks at times other than main meal times. We saw a meal being served during the inspection. This was roast beef with vegetables, and everyone we spoke to said it was a nice meal and the meat was very tender. There is information in care records about what people do and don’t like to eat. 60 of people returning surveys said they like the meals at the home and 40 said they sometimes like the meals. One person said, “I enjoy breakfast and tea, but lunch is not always very nice”, and another person said, “I do not like minced meat so when there is minced meat (e.g. shepherd’s pie) on the menu I usually have a salad”. Two other people said they didn’t think the food provided was of particularly good quality. Staffing levels at meal times is not very high and this means that people who need help to eat sometimes have to wait a long time between sitting down and getting their meal. Residents in one dining room were sitting at tables at 12.30pm, meals were not delivered for another 20 minutes and some people were still eating dessert at 1.40pm, an hour and 10 minutes after they had sat down. There was only one staff member for most of the time helping people, although another staff member helped her at some times. Manor House DS0000024320.V358595.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 and 18 Quality in this outcome area is good. People have enough information for them to be able to raise concerns and have them dealt with in the correct way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure that is on display in the home and available to people living there. The acting manager said there have been no complaints made in the 12 months before this inspection, although information provided to the Commission shows there were 4 complaints made in the 12 months to December 2007. Three of these complaints had been responded to within 28 days and one of the complaints had been upheld. 5 out of 6 people at the home and 9 out of 10 visitors who returned surveys said they know how to make a complaint. People at the home said they know who to speak to if they’re not happy and everyone said staff listen to what they are told and act on the information. One person said, “They listen to any comments from either myself or my father and react accordingly”. There have been no safeguarding adults referrals in the last 12 months. A training matrix for staff members shows that all staff have received training in protecting people from abuse in 2007. Manor House DS0000024320.V358595.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 and 26 Quality in this outcome area is adequate. Most of the environment offers people who live at the home a safe and pleasant area in which to spend their time. Part of the building presents risks to residents and staff and action must be taken to improve the health and safety, and dignity for people living in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Everyone who returned surveys said the how is fresh and clean and we found this was the case during the inspection. There is one main lounge area, with chairs and footstools in other areas around the home for people to use. The home is nicely decorated and provides a comfortable place for people to live. People are able to bring personal belongings into the home with them to personalise their rooms. Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 17 However, the limited width of one corridor (South Wing) in the home puts people with rooms there at risk. The corridor is not wide enough for moving and handling equipment, such as hoists, or emergency equipment, such as stretchers, to be taken down the corridor to people’s bedrooms. This means that anyone who needs to be moved has to be lifted and carried along the corridor to the main corridor in the home. This is degrading and undignified, as well as putting the person, care staff and any other care professional at risk of injury. The acting manager said two people have needed to be moved this way in the last few months. Information has been provided by BUPA regarding renovation of South Wing, with a proposed date for July 2008. However, an exact date has not been confirmed and the acting manager was not aware of any plans to move people still living in rooms in South Wing to other rooms in the home. This has been an issue for the last few years and the Commission will obtain legal advice regarding use of this wing. Manor House DS0000024320.V358595.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 and 30 Quality in this outcome area is adequate. Staffing levels do not always ensure people are not kept waiting for help when they need it. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most of the people who returned surveys (including staff members) and people we spoke to during the inspection said there are not enough staff at the home. They also said that staff are usually available when they are needed, and visitors we spoke to said people don’t usually have to wait too long before staff members are able to help them. Information provided to the Commission shows the home has 14 people who need help with eating. Staff who were helping people to eat did this in a sensitive way that encouraged people to do as much as they could for themselves. However, it was noticeable, because of the length of time that lunch took, that there were not enough staff to help people with their meals. The staff rota shows there are usually between 6 and 7 staff members, including registered nurses on duty during the day. This gave a ratio of about 1 staff member to 6 or 7 people at the time of the inspection, which is acceptable, but may not be enough at times when many staff members are needed to help. Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 19 All staff receive mandatory health and safety training when they first start working at the home as part of their induction programme. Training records show all staff training in these areas is up to date. Just over one third of nonnursing care staff have a NVQ in care at level 2 or above and information shows there are another 6 staff members completing the qualification. Four registered nurses at the home have received training in palliative care. Staff files for 2 people employed since the last key inspection were looked at to see if required checks and information had been obtained before they started working at the home. The files showed this has been done with the exception of one reference that had not been received until after the person started working at the home. As all other information was available, a requirement will not be made at this stage. Manor House DS0000024320.V358595.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 and 38 Quality in this outcome area is adequate. Although there is no permanent manager the home has enough support to make sure people living there are safe and they are able to have a say in how it is run. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection the acting manager was in charge of the home. She is a nurse, registered with the Nursing and Midwifery Council, and has experience working in other care homes and hospitals. She was working as the deputy manager at this home before moving to the acting manager role, but is also having to fulfil other roles, such as administrator as there is no-one in this position either. The previous manager has been seconded to another role within the organisation and had not been at the home for some weeks. The Commission had been advised of this. People living at the home have
Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 21 noticed not having a manager, one person commented, “usually I speak to the Manager, but he is often away, and recently for several weeks”. We have been told the managers from two other BUPA homes are supporting and overseeing the home at this time. The home carried out a quality assurance at the end of 2007. A report will be produced by the organisation’s head office, showing how the home has improved or not since the previous report. The home has to complete an action plan for areas that have been identified as needing improvement. Residents meetings are held every 3 months, minutes are kept and copies of these are available. The home does not hold money on behalf of people who live there. If charges are made, such as hairdressing or chiropody, these are invoiced to the person or whoever manages their money. People are able to keep money with them and lockable drawers are available in each room for safekeeping of these. Information provided before the inspection shows that health and safety maintenance and servicing is carried out at the required intervals. Fire equipment was looked at when we walked round the building and this has been checked within the last year. Manor House DS0000024320.V358595.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(2) Requirement Medication must be stored securely so that people are not put at risk. (The previous timescale for this requirement has not been met.) 2 OP19 23(1) Areas of the home to which residents have access must be safe for care staff and other professionals to work in. The organisation must provide information about how and when this is to be achieved. (The previous timescale for this requirement has not been met.) 31/03/08 Timescale for action 29/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 24 No. 1 Refer to Standard OP27 Good Practice Recommendations The home should consider increasing staffing levels at busy times, i.e. during lunch time. Manor House DS0000024320.V358595.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Inspection Team Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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
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