Inspection on 20/07/05 for Manor House Christian Rest Home

This inspection was carried out on 20th July 2005.

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 Christian Rest Home 01/05/08

Manor House Christian Rest Home 08/05/07

Manor House Christian Rest Home 31/05/06

Manor House Christian Rest Home 28/11/05

Manor House Christian Rest Home 06/01/05

Manor House Christian Rest Home 11/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Manor House Christian Rest Home Bacton Stowmarket Suffolk IP14 4LJ Lead Inspector Anna Rogers Announced 20 July 2005 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 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 Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Manor House Christian Rest Home Address Bacton Stowmarket Suffolk IP14 4LJ 01449 781447 01449 781447 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Manor House Christian Trust Mrs Miranda Jane Jolly Care Home 16 Category(ies) of OP Old Age (16) registration, with number of places Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection Brief Description of the Service: Manor House Christian Rest Home is a large 16th Century building situated in the centre of the village of Bacton, close to local amenities. It is surrounded by approximately three acres of grounds which include an orchard to the rear of the property. There is a large farm to one side of the home and a GP surgery to the other side. The building is privately owned and leased by the Manor House Christian Trust for the purpose of providing residential accommodation for older people, within a Christian community. The Trust are somewhat restricted as to any adaptations they can make to the property as it is a listed building and formal negotiation is required before any permission will be given to make any changes. The Trust are responsible for the upkeep and maintenance of the property. The home offers accommodation and care for up to sixteen older people, the majority of whom are practicing Christians. However, local people who do not follow the Christian faith would not be precluded from living at the home. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and started at 10 am. It took place over seven and a half hours during a weekday. Time was spent with four staff on duty including the registered manager. A tour of the premises was made. A number of records were examined including those relating to the care of residents and staff records including supervision and training. Seven residents were spoken with individually and others were spoken with in groups in the residents lounge. Three relatives and seven residents completed comment cards about the service provided at the home. What the service does well: The staff team clearly see it as important to be available and to support residents. Residents spoken with said, “Members of staff are wonderful,” “they can’t do enough for you.” Residents commented on the happy atmosphere at the home and this was evident during this inspection where it was clear that relationships between staff and residents are very positive. Two residents mentioned, “The family atmosphere that exists” and another said, “it is like a large family.” The nutritional needs of residents are monitored and new residents have a nutritional assessment on admission and as part of the on going monitoring all residents weight is checked monthly with clear arrangements for action if there is a significant weight loss or gain. Meals at the home provide a good choice and are varied. The inspector joined residents for lunch in the dining room. The atmosphere was relaxed with staff available to assist and/or encourage residents with their meals. There was appropriate good-humoured bantering between staff and residents and the mealtime was unhurried. Residents said, “The food here is very good,” “I have a cooked breakfast each day, which is the meal I most enjoy.” Another resident said, “We are offered drinks throughout the day as well as at lunchtime.” Relatives who completed a feedback form also expressed satisfaction about the care provided. Relatives commented, “Manor House is an excellent run care home” “ all staff care for ---- wonderfully” “would highly recommend the home to anyone” “ excellent home, run so friendly, we’re made so welcome by staff and management, we look forward to going there”. The staff team are provided with good opportunities for training and were able to identify the benefits that training brings but were also clear that residents should be respected and have a right to be cared for “as you would wish to be cared for.” Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: It remains a matter of concern to the Commission for Social Care Inspection (CSCI) that the Trust board have not responded to a requirement to develop a business plan to ensure the ongoing financial viability of the home. The Trust board also need to develop a system as required by Regulation 26 of the Care Homes Regulations that ensures the practice and care of residents is monitored. The practice relating to ‘secondary dispensing’ of prescribed medication must be reviewed as it is an unsafe practice and does not ensure the protection of residents. Residents are generally satisfied with their care but mention was made both during discussions with residents and confirmed in three of the completed feedback cards that the range and choice of activities are very limited. A requirement to develop activities both in and outside of the home has been made. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 7 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. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 &2. Standard 6 does not apply to this service. Residents can expect to be provided with a copy of the homes Statement of Purpose and Residents Guide that will set out how the home will care for them but they cannot be assured that practice will be monitored regularly as required by Regulation 26 of the Care Homes Regulations. EVIDENCE: The organisation has, since the last inspection, produced a detailed Service Users Guide. It is presented with coloured pictures of areas of the home. There is also information about the terms and conditions of residency. The information also contains a summary of the home’s Statement of Purpose. From discussion with staff and residents it is clear that the home provides the care described in the Service Users Guide and that the Manager monitors the day to day practice but it is concerning that a repeat requirement for monthly monitoring visits as set down in Regulation 26 has not been actioned by members of the Trust Board. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Residents can expect they will be treated with respect and privacy will be upheld. They will be given good access to healthcare. However, the administration of medicines is not carried out in a manner that assures the safety and welfare of residents. EVIDENCE: Three of the resident’s files were inspected. They each contained appropriate background information including personal histories and daily routines. It was evident from discussion with the Manager that resident’s involvement is encouraged in identifying their needs and wishes. It is recommended that residents are encouraged to sign their care plan to indicate their involvement. The key worker of each resident writes the care plan. Each care plan contained the identified aims but there is a need to develop how the aims are to be addressed. There was evidence that care plans are reviewed on a monthly basis. If a resident is involved in the review this should be recorded on the plan to indicate the plan has been discussed with them. A copy of the care plan relating to personal care is kept in the resident’s bedroom with clear instructions that care staff consult and sign each day to confirm that elements of the residents personal care has been addressed. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 11 Each of the files examined had a risk assessment relating to moving and handling which identified the risk of falls. Each care plan provides good evidence that resident’s personal and health care needs are addressed. There was evidence of specialist involvement for example GP, Opticians, Chiropodists, and District Nurses. Continence needs are assessed and residents have their own continence products ordered specifically for them. There is also a pre-prepared form for each resident with relevant personal details that would be sent to a hospital in the case of an unforeseen admission. A very positive development from the last inspection is the completion of nutritional assessments. The two cooks attended a Nutritional Dietary course in December 2004 and eight care staff attended an in house course provided by a Dietician. All residents have a nutritional assessment and are weighed monthly. If there is a significant increase or drop in weight staff are aware of the action they should take for example referral to the local GP and/or provision of build up drinks. The assessments are well recorded but advice was given to also include the dexterity of the resident and whether specialist cutlery is required. There is a need to ensure all nutritional assessments are dated and signed by those involved in the assessment. The Manager has also responded positively to the requirement made in relation to resident’s susceptibility to developing pressure areas. There was evidence that risk assessments are completed in conjunction with the District Nurse. One resident has been identified as a high risk of developing a pressure area. The Manager confirmed that the area is routinely creamed and monitored by the District Nurse who visits the home weekly. As with the nutritional assessments there is a need to ensure all assessments are dated and signed by those involved in the assessment. Two requirements relating to medication have been actioned from the last inspection. The temperature of the medication refrigerator and the medication room are now monitored and the temperatures recorded indicate that the temperatures remain within the safe range. On the day of this inspection the refrigerator temperature was 2°C and the temperature of the room was 24°C. The home’s medication is provided by a local dispensary on a monthly basis. It was noted at this inspection that prior to the administration of medicines by care staff either the manager or the assistant manager dispenses medicines on a weekly basis into Dosette boxes from containers originally supplied by the dispensary. This creates an additional step in the preparation of medicines for administration and is considered to be unsafe practice and classified as ‘secondary dispensing’, which is an unacceptable procedure and must cease. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 12 Care staff administers the medication from the prepared dossette boxes, which are witnessed by a second member of staff, and both sign the Medication Administration Records (MAR) charts. Routine prescribed medication is recorded on the dossette box but if a resident has been prescribed antibiotics the name is recorded on a separate sheet rather than the dossette box. A recommendation from the last inspection relating to having a controlled drugs register has been actioned. The assistant manager confirmed that currently none of the residents have been prescribed medication that is seen as a controlled drug. Discussion with residents indicated that staff are very respectful when undertaking personal care to ensure the privacy of the resident. There was evidence from observation that staff knock on bedroom and toilet doors before entering. There was evidence in records and confirmed in discussion with residents that they are known by their preferred name. Residents were all appropriately dressed for the temperature and weather conditions and clothing all looked cared for. From observation it was clear that relationships between staff and residents were positive with good-humoured bantering on both sides. Residents spoken with said staff were respectful and helpful. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Residents can expect to be offered a limited range of activities and outings. The arrangements at the home encourage visits from resident’s family and friends. Residents can expect to have a choice of meals. EVIDENCE: The home is founded upon Christian beliefs, although service users who had different beliefs were not precluded from living at the home. In terms of their spiritual needs, the manager said that one of the trustees led a devotion service each morning between the hours of 9am–11am. Residents spoken with confirmed this. Speakers are also invited to the home from various church networks in Suffolk. Residents spoken with during this inspection were very complimentary about the care they receive at the home but a number did comment that they would welcome a wider range of activities as they do feel that some days are long and boring. Members of the staff team have recently introduced an indoor skittles game, which a number of residents including those with mobility difficulties thought was very good. An Accordion player also visits the home to play for the residents. Staff spoken with said they had held a function at the home, which raised money for a recently introduced residents amenity fund to pay for entertainers such as the Accordion Player. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 14 The manager said that the home is run as a non-profit organisation based on Christian principles that the Trustees feel should be reflected in activities. However there is a need to review the arrangements in place to ensure residents are provided with a wider range activities both within and outside the home. It was evident from discussion with staff, residents and confirmed in records that relatives and friends are welcomed to visit the home. The records confirm that resident’s involvement in the community comes mainly from relatives or friends taking residents out. Residents spoken with said that they made choices about the time of getting up and going to bed, what clothes to wear and a choice of meals. The inspector joined the residents for lunch. The meal was well cooked and attractively presented. Two different main courses and a choice of puddings were provided. The inspector noted that the staff supported some residents eating their meal in an unhurried and sensitive manner. Residents spoken with said they were satisfied with the food provided. There is a small dining room with four tables with seating for four people at each table. It was noted that everybody decided to have their meal in the dining room and the atmosphere was relaxed with quiet chatter at each table. Residents are able to access their places with walking aids, which are then moved outside of the dining room during the meal to aid access to each table by staff serving the plated meals. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 &18 There is an effective system in place for residents to express their concerns. The home has a clear policy and procedure in place for dealing with allegations or suspicions of abuse. Residents can be assured that the recruitment safeguards have been followed to protect their safety. EVIDENCE: No formal complaints had been received since the last inspection. The manager has implemented a minor complaints log of concerns that can be resolved quickly. The record indicates that no minor complaints have been received since the last inspection. Residents spoken with said they thought they could complain to the manager or another member of staff but none felt they had any complaints. The recruitment records of four new members of staff recruited since the last inspection were seen and these showed that appropriate checks including Criminal Record Bureau (CRB) checks and references are being undertaken prior to staff undertaking duties. Where Criminal Record Bureau (CRB) checks have not been received there was evidence that Pova 1st checks had been undertaken and staff have not worked unsupervised until their Criminal Record Bureau (CRB) check has been received. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,24,25,26 Residents can expect to live in a safe environment. Residents who use this service can expect all communal areas to be clean and fresh and they will be able to personalise their own bedrooms. EVIDENCE: Residents are encouraged to see Manor House as their home. An effective system is in place to ensure the building is maintained. A new carpet has been fitted in bedroom 12 but replacement of the carpet in room 2 remains outstanding. The manager confirmed that they do not have a budget for replacing furnishings or fittings but have to report to the Trustees. The home is equipped with aids and adaptations to support residents, for example such as raised toilet seats, raised armchairs, grab rails, assisted baths which is routinely serviced and a fully operational call bell system. It was noted at the last inspection that the call bell rope in toilet number 12 had been tied up but all call bell ropes seen during this inspection were readily available to residents. Discussion with residents confirmed that staff responded quickly to a call for assistance. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 17 Access to some of the first floor bedrooms is by a vertical passenger lift, which was fully operational and takes two residents at a time. A stair lift is available to access the other upstairs bedrooms above the back staircase, which are not accessible via the passenger lift. The manager confirmed that these bedrooms are not suitable for residents with significant mobility difficulties. Residents are provided with the basic furniture for their bedroom including a bed, wardrobe bedside locker with a lockable drawer, and a chest of drawers. They are able to personalise their rooms with small items from their own homes if they wish. Residents spoken with said they were happy with their rooms. There are two double bedrooms, married couple uses one and the other currently only has one resident but there is a curtain to divide the bedroom if required. All bedrooms have a wash hand basin and one bedroom has an ensuite bath with a separate toilet. All bedrooms have central heating. Some bedrooms at the front of the building have secondary glazing for use during the colder weather. Radiators have been fitted with covers. It was noted at the last inspection that the temperature of the hot water in the ground floor bathroom was in excess of the safe water temperature. This was tested during this inspection and the temperature read just under 46°C. It was also noted that the thermometer used by staff to test the water before a resident gets in the bath was not working effectively and needs replacing. A written record is kept to say the water temperature has been tested but does not include the temperature of the water. It is recommended that the temperature is recorded to enable the manager to monitor the effectiveness of the thermostatic controls fitted to hot water outlets. All the residents’ laundry is washed at the home. The manager reported that since the last inspection a new washing machine has been provided which has a sluice facility for dealing with soiled laundry. A requirement from the last inspection relating to the provision of liquid soap and paper towels has been actioned in all but one toilet on the ground floor. This must be addressed. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Residents can expect to be cared for by staff who have the skills, training and knowledge to care for them. The recruitment checks for staff are thorough which ensures residents are protected. EVIDENCE: The staff rotas indicated that either the manager or the assistant manager is on duty each day apart from when they are on holiday. The rotas also indicated that there are usually three staff on duty during the morning, two on the early afternoon with a third available from 18.00 – 22 .00. At night there are two waking night staff on duty. These staffing levels were felt to be appropriate to meet the needs of the present resident group. The Manager said that there was a commitment for staff to undertake a (National Vocational Qualification) NVQ. Staff spoken with had all completed either and/or NVQ level 2 or 3 qualification. The manager reported that currently 40 of the staff team hold an NVQ qualification. There was also evidence that new members of staff undertake induction and foundation training at Kerrison Training Centre. The training record confirmed that staff undertake a manual handling induction prior to undertaking care duties and then attend an annual update with other staff. The manager said that new members of staff receive fire safety training within the first week of starting. It was recommended that staff are shown the fire safety procedures on their first day at the home and that this is reflected in their training record rather than a tick to show that the instruction has been given. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 19 Recruitment procedures are clear. The files of new staff were inspected and found to be satisfactory. It was noted that members of staff Criminal Record Bureau (CRB) check is kept on file. Advice was given to the manager that once an inspector from The Commission for Social Care Inspection (CSCI) has checked the recruitment checks of new staff that under the Data Protection Act they are only required to keep a record of the member of staffs’ (Criminal Record Bureau (CRB) check number and issue date. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35,36, 37, 38 Residents cannot be assured that practice will be monitored by the Trust board as required by Regulation 26 of the Care Homes Regulations. Residents can expect their finances to be safeguarded by an effective recording and monitoring system but they cannot be assured that the Trust board will confirm the ongoing financial viability of the home. Residents can expect their safety and welfare to be risk assessed and to be cared for by a staff team who are supervised and supported by senior staff. EVIDENCE: There continues to be no official monitoring visits as required under Regulation 26 of the Care Homes Regulations. These visits must be undertaken by a member of the Trust board (or someone acting on behalf of the Trust board), must be unannounced, must inspect the premises, care records and interview staff and residents in order to form an opinion of the standard of care being provided at the home. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 21 A written report must be prepared in relation to each visit with a copy being provided to the manager, each member of the Trust board and the CSCI. This requirement is repeated from the last two inspections. The manager is commended for developing a questionnaire to ascertain the views of residents and relatives about personal care and support, catering and food, daily living, the environment and the day-to-day management of the home. There is also a separate questionnaire that a new resident is invited to complete about their admission. Advice was given to date the questionnaires. From discussion with the manager it is clear that adverse comments/suggestions are followed up but this information is not recorded to show the action. There was no evidence to show that the Trust board has produced a business plan following a requirement from the last two inspections. It remains a matter of concern to The Commission for Social Care Inspection (CSCI) that sufficient planning has still not been done to ensure the ongoing financial viability of the home. The home will look after money for residents including money provided by relatives. This is kept in a safe and the manager or assistant manager holds the key. Separate records are kept of resident’s personal allowances (kept in separate wallets). Money taken out or put in is signed for. If a member of staff purchases shopping on behalf of the resident a receipt showing the amount and what was purchased is kept. Advice was given to number the entry and the receipt to enable effective cross-referencing. There was evidence that there is an effective system in place to ensure care staff receive formal individual supervision minimally six times a year. The manager has introduced a supervision format for recording the session but is going to review this to ensure it is effective. The manager does not receive formal supervision and this should be explored with the Trust board to ensure the manager has an opportunity to discuss their practice and training needs. A number of records including care plans, nutritional assessments, risk assessments, daily notes, medical notes, and resident’s questionnaires were seen during this inspection. A recommendation is made to ensure all entries are in ink, are dated, and signed and corrective fluid should not be used. There was evidence in resident’s files that risk assessments have been undertaken in moving and handling and are reviewed. Staff files showed that staff attended mandatory training including moving and handling, first aid, health and safety, food hygiene, and fire safety. The induction for staff of the fire procedure for the home should be undertaken on their first day. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 22 Staff are provided with gloves and disposable aprons and there was evidence of a ready supply being available. As noted in the environment section of this report that there is a need to ensure the temperature of hot water is maintained at a safe temperature and that the thermometer used is working effectively. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 2 3 3 2 3 Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 9 Regulation 13 (2) Requirement The registered person must ensure that safe procedures for medicine handling and administration are followed at all times. The registered person must ensure that a programme of activities are provided. The registered persons must ensure that the hot water delivered to the downstairs bath is delivered at close to 43°C. The registered persons must ensure that thermometer used to test temperature of hot water is working effectively. The registered persons must ensure that liquid soap and paper towels are available in all bathrooms and toilets. The registered persons must ensure that monthly unannounced visits are undertaken at the care home. During these visits the care home must be inspected, service users and staff interviewed and a written report prepared and sent to the manager, all directors of the organisation and the CSCI. This requirement is repeated Timescale for action By August 31st 2005 2. 3. 12 25 &38 16 (n) 13(4) By August 31st 2005 By August 31st 2005 Immediate 4. 25 & 38 13 (4) 5. 26 13 (3) & 16 (2) (j) 26 Immediate 6. 33 By 31st August 2005 Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 25 from the last two inspections. 7. 34 25 (1) The registered persons must produce a business plan or equivalent document to demonstrate that the home will continue to be financially viable in order to achieve the aims and objectives as set out in the statement of purpose and as required by Regulation. This requirement is repeated from the last two inspections. The registered persons must replace the carpet in bedroom 2. By 31st August 2005 8. 9. 19 23 (2) (d) By October 30th 2005 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. Refer to Standard 25 & 38 30 & 38 36 37 Good Practice Recommendations the temperature of the hot water should be recorded to enable the manager to monitor the effectiveness of the thermostatic controls fitted to hot water outlets. New members of staff should be the fire safety procedures on their first day at the home and that this is reflected in their training record. The supervision arrangements for the manager should be explored. All record entries should be in ink, dated, signed and corrective fluid should not be used. Manor House Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 5th Floor St Vincent House Cutler Street Ipswich IP1 1UQ National Enquiry Line: 0845 015 0120 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 Christian Rest Home I54 - I04 S24441 Manor House V230190 050720 Stage 4.doc Version 1.40 Page 27 - 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. 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