Inspection on 08/05/07 for Manor House Christian Rest Home

This inspection was carried out on 8th May 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 Christian Rest Home 01/05/08

Manor House Christian Rest Home 31/05/06

Manor House Christian Rest Home 28/11/05

Manor House Christian Rest Home 20/07/05

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 Jo Govett Unannounced Inspection 8th May 2007 10:15 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 Christian Rest Home DS0000024441.V340358.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 Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor House Christian Rest Home Address Bacton Stowmarket Suffolk IP14 4LJ 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) 01449 781447 01449 781447 Manor House Christian Trust Mrs Miranda Jane Jolly Mrs Miranda Jolly Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2006 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 that 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 DS0000024441.V340358.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced “Key” inspection, which focused on the core standards relating to Care Homes for Older People. The report has been written using accumulated evidence gathered prior to and during the inspection. The Registered Manager, Miranda Jolly was on annual leave at the time of the inspection but we were able to discuss issues and give feedback over the telephone on her return. At the inspection the Deputy Manager was very helpful and informative, providing documentation and records. They were also working on shift providing care for residents. All the staff on duty were helpful, friendly and positive throughout. Surveys from 13 residents, 5 relatives/carers and/or advocates and 10 care workers were returned directly to the CSCI. The agency submitted a Pre Inspection Questionnaire. Comments from completed surveys and discussion with residents, staff and other interested parties, have been incorporated into this report. What the service does well: • • The atmosphere at the home is welcoming and friendly, from both staff and residents. Residents commented that staff listened to what they had to say and said they were kind and friendly. Residents spoken with said they found the Registered Manager very approachable and willing to spend time with them. Comments included; “I would have no hesitation in talking to them if there were any problems” and “ … they are all very competent and we trust them”. Private bedrooms are very comfortable and homely, reflect resident’s personalities and allow for resident’s own possessions around them. The home has strong community contacts and benefits from the close proximity of the local GP practice. Many the staff are long standing employees, giving the home a stable and consistent approach and staff who know the residents well. • • • What has improved since the last inspection? • • The homes abuse policy and procedure has been updated to reflect local guidelines on the Protection of Vulnerable Adults (POVA) There are more organised activities at the home and an awareness of the importance of keeping residents stimulated and interested. Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 6 • Photographs of residents have been added to their Medication Administration Records (MAR) to further protect them from mistakes in identification or administration. What they could do better: • Although the home provides some very positive outcomes for resident, this is very reliant on the good attitude and commitment of staff. The Registered Manager’s ability to manage on a day-to-day basis is limited by the control the Trust’s board has over budgets and planning. In order to maintain and improve, the home must start to develop its organisation and management systems, to evidence it can keep up with good management planning and practice and encourages innovation, creativity and development. This has effected the quality ratings in some areas. Some areas of the home need to be refurbished and redecorated, with consideration given to the abilities and needs of residents. Staff commented they would benefit from some more in depth training in areas like medication and risk assessment. Where controlled medication is administered the number received and the number that remain (after administration) must be logged. This is for the safety and security of staff and residents. A safe and secure method of transporting medication around the home needs to be adopted for the same reason The home needs to ensure that applicants provide a full working history with an explanation of any gaps. • • • • 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 Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5 (Standard 6 is not applicable) Quality in this outcome area is good. Residents can expect the home to assess their needs and discuss the care they can provide prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The assessments of three residents who had moved into the home since the last inspection were seen. There was evidence that each person and or their relatives/representatives had been involved at this initial stage. They had details on significant health factors, which the home considers whether it is able to meet prior to offering care. This information had then been developed into a care plan. Two residents confirmed that they had a contract and terms and conditions. Resident’s files also contained this information. One resident said that they had been able to visit the home and talk with staff and other residents before committing themselves to move in. Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 9 Manor House Christian Rest Home DS0000024441.V340358.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): Quality in this outcome area is adequate. The home places a high priority on consulting residents about their care and support. However improvements around medication and the environment are needed to safeguard residents from harm and protect their privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has continued to develop care plans, with evidence of resident involvement and consultation. They cover mobility, continence, oral hygiene, diet, hearing, sight, mobility, and medication. In addition there were entries for personalising residents private rooms, their preferred daily routine, social and spiritual needs and their final wishes, including who to contact for making the arrangements. There were risk assessments for moving and handling and for undertaking activities. It was fedback that some health care needs had not been risk assessed for example, continence (which may effect skin viability), medication (side effects, conditions) and heart problems. The Registered Manager agreed that training in this area was needed. Care records show that health professionals e.g. community nurses, opticians chiropodist visit residents regularly. Residents are registered at the GP surgery Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 11 opposite the home. The GP visits the home routinely once a week but the home confirmed they can be called at any time if needed. One person commented that “I have needed a lot of medical support since being here and it’s first class”. The last inspection required the home to include photographs on the Medication Administration Records to ensure the identification of each resident against their prescribed medication. This had been completed and a passportsized photo had been added to the record. The inspector completed a short audit of the medication kept at the home. Where medication was provided in a blister pack there was a clear audit trail with signed records of administration. The controlled medication book, where staff double sign for medication, (for safety and security reasons) did not record the amount of tablets given and then left in the pack. A medication round was observed during the lunch period. The staff member responsible had undertaken appropriate training. They provided resident’s medication in a supportive way and gave choices in a considerate manner (given that other residents were nearby). The medication is transported from a locked cabinet in a medication room via a plastic box. It was fedback that this system may not always be safe, as there may be circumstances when the box is left unattended and for staff’s own health and safety (moving and handling). It was advised medication must be moved around the home safely and securely in line with guidance issued by the Royal Pharmaceutical Society (i.e., a lockable trolley). Staff comments gathered prior to and during the inspection included that they would like to have some further more detailed medication training and that this would increase their confidence in this area. Residents commented that in general staff treated them with respect and listened to what they had to say. During the inspection staff were seen chatting with residents, asking their opinions and knocking on doors before entering their private bedrooms. As noted in the section Environment the swing doors on some toilet doors were not easily locked, allowing them to be opened by others when the were in use (as observed during the inspection). Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People living at the home can expect the home to encourage contact with relatives, friends and the local community. They also benefit from a good choice of meals which they are consulted about. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents confirmed that they were able to receive visitors, friends and family at the home. The home has strong links with the local community and has developed activities and social events involving local people. There is a morning prayer meeting every day, which resident can choose to partake in if they wish. Two residents confirmed they attended sometimes but did not feel they had to. The last inspection repeated a requirement for programmed activities to be implemented. At this visit a weekly log showed that a variety of activities had been happening at the home on a daily basis. This included organised events like visiting entertainers, pantomime and visits by local children and Woman’s Institute. In addition staff organise quiz afternoons, reminiscence, board games and walks around the grounds. Residents commented positively about a local person who visits regularly and plays his squeezebox. Independent residents are able to walk the grounds of the main house, or go to the village. In answer to the question “Are there activities arranged by the home that you Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 13 can take part in?” Six said “Always” four said “Usually” and three said “Sometimes”. It was fedback that this was an improvement although there was no record on individuals care records to show how these needs are being met individually. For example it was not possible to tell who had attended group activities. In some cases daily records did not reflect the individual activities residents were involved with, such as listening to music, knitting, reading etc. The Inspector was able to observe lunch. The cooks informed the inspector that one option was curry because of a request from a resident. Residents commented that they enjoyed the food provided. Most residents chose to eat in the dining room, but staff confirmed that residents could have meals in their own private rooms or any of the lounges. Residents were able to take their time, talking with staff and other residents. Those that required help were assisted by staff promptly and without drawing unnecessary attention to their needs. Comments included: “ were else can you get five different choices for pudding?” and “Food is plentiful and tasty”. Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. Residents can expect the home to listen to their concerns and take appropriate action to address them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No concerns were raised with the CSCI through surveys and the visit to the home. Those who returned surveys all confirmed they knew how to complain. Residents spoken with during the visit said they felt able to approach the Registered Manager and Deputy about any worries. A complaints log was available and mainly contained comments regarding food quality. These had been fedback to the kitchen staff and appropriate action had been taken. Some entries did not include the action taken to resolve issues. However this could be tracked in individual files. There were no anonymous complaints logged. The previous inspection required the home to up date its Protection of Vulnerable Adults policy in line with local procedures. This had been completed. New staff had completed training around abuse during their induction and refresher training is provided for existing staff. Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 & 26. Quality in this outcome area is adequate. Residents can expect the home to feel comfortable and homely. The Registered Manager and Deputy recognise that improvements to décor and some facilities would go further to ensure the home continues to operate for the benefit of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last inspection recorded that “Manor House is an attractive listed building with high ceilings and lovely rural outlooks. The gardens are well maintained and have areas for outdoor seating, which staff said are used in the good weather. Residents’ individual rooms were seen and were all different in size and outlook because of the layout of the house. Some residents had chosen to have their own furniture in their rooms; others had decided to have their own bed linen.” This inspection confirmed this was still the case. In answer to the question “Is the home fresh and clean?”, twelve out of thirteen residents who answered said “Always”. It was fedback to the Registered Manager and Deputy Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 16 that some areas of the home are tired and shabby. For example in some areas there was scratched and peeling paintwork, some overhead light shades were discoloured and had a significant amount of dead flies in them (this added to the dark feel in one corridor), and some carpets had a lot of wear and tear. Although the downstairs bathroom had had some refurbishment completed the room was very bare with some paint -work coming of the wall and a gap in the bath housing. The Registered Manager confirmed that a grant had been obtained to make improvements to this bathroom and the main lounge. Despite this there were no negative comments from residents. There was a homely atmosphere with one person commenting they liked the furniture and décor because it “reminds me of my home”. As noted in the section Personal Care some toilet doors operate on a swing door basis. This means that if the door is not locked properly (as observed during the inspection) it is still possible to open the door outwards so that the occupant can be seen. All staff complete training on infection control and Control of Substances hazardous to Health (COSHH) during their induction. It was observed that commode pots are bleached and disinfected in the laundry. Although clean laundry was ironed and stored in an adjacent room, this could be an area for potential cross infection. The Registered Manager confirmed that the “pot washer” had not been working for a long period and needed mending. Discussion with the Registered Manager identified that the registered providers (the Trust) usually organise for/complete the maintenance work at the home. The Registered Manager does not have direct control over a budget for any area of the home including maintenance and repairs. This limits their ability to take action to address issues as they arise. Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 17 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. Overall residents can expect the home to recruit staff appropriately, although they must ensure that a full working history is obtained for each new employee to further safeguard residents. More in depth training in medication and risk assessment would benefit residents and improve the confidence and competence of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff files of two staff who had been employed since the last inspection, were seen. They included all the information required such as identification and references. It was fedback that the information on the applications was minimal and that there was not a full work history, which is required together with a satisfactory written explanation of any gaps in employment. Each staff member has a training record in place. In addition there is a general training folder that included information on training dates and the staff who need to attend. This included moving and handling, abuse, health and safety, fire safety, first aid, dementia, diabetes, bereavement and food hygiene. Not all the certificates were in place on the files seen. Four out of the five surveys returned by relatives, carers and advocates said that the care staff “Always” have the right skills and experience to look after people properly. One said this was “Usually” the case Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 18 The Registered Manager confirmed that nine staff have completed National Vocational Qualifications (NVQ) at Level 2 and five at Level 3. This meets the requirement to have at least 50 of staff achieving NVQ2 or above, with the actual figure standing at 63.6 . A further six members of staff are either nearing completion or enrolling in an NVQs. Comments gathered from staff included that they felt more detailed training around handling medication would give them more confidence. In addition it was highlighted that staff undertaking risk assessments need to have relevant training to do so. All ten staff surveys returned said that they felt they had received sufficient training to undertake their role. The Deputy Manager confirmed that the rota reflected the staff on duty – with 3-4 staff on each morning and 2 in the afternoons and at night. In addition there are domestic staff and cooks. During the visit all staff were friendly and interested in speaking with residents. Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 19 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, 36 & 38. Quality in this outcome area is adequate. Residents benefit from the ethos of the home and generally experience good outcomes. However the current organisational structure does not evidence or ensure the development of best practice and improvements in key areas such as environment and training. This has effected the overall quality rating in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has worked at the home for several years, as a carer, and as an assistant manager. They have completed the Registered Managers Award and continue to update their practice by attending refresher training and information sessions. They shared that they had been unable to keep some of their professional information links due to subscriptions being halted through budget cuts. The previous sections in this report have identified where Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 20 the home could improve, such as the environment and additional training. The Registered Manager has limited ability to control this, as all budgets and spending are managed by the registered provider (the Trust). The home has been successful in obtaining a grant for some improvements to the environment. During the inspection it was unclear how the Registered Manager could forward plan and keep up with best practice in social care, without knowing the budgets for key areas. There is a supervision and appraisal system in place for staff, however there was no evidence that the Registered Manager has received supervision or appraisal from the registered provider. Residents who returned a survey and talked with during the inspection were positive about the home. Ten out of thirteen surveys said that they “Always” receive the care and support they need, and three stated this was “Usually” the case. All thirteen said that the staff listen and act on what they say. The Deputy Manager demonstrated how resident’s personal money is looked after. There is a clear audit trail including receipts and log books for each individual. The home keeps records of health and safety checks. At this inspection the fire alarm, emergency lighting and water temperature records were seen and found to be satisfactory. When problems had occurred the home had taken appropriate action. The home had acted in response to new fire risk assessment requirements by making some changes to a fire door and ensuring that fire doors are not wedged open. CSCI has requested confirmation from the Registered Manager that their actions meet the requirements of the fire service. The last inspection recorded concerns over a gas supply. Information provided following that visit confirmed this had been rectified and that the home no longer has a gas supply. Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 21 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 2 X 2 Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 13(4) 14 Requirement Where there is an identified risk an appropriate risk assessment must be in place for the protection of resident’s health and welfare. Staff completing risk assessments must be appropriately trained to safeguard the health and welfare of residents. The controlled drug book must record the amount of controlled drugs that are received, given and remain. This will ensure that controlled drugs are monitored for the safety and security of staff and residents. New employees application forms must include a full work history with an explanation of any gaps, in order to safeguard residents from unsuitable staff. The homes environment and facilities must be appropriately maintained and/or updated to ensure that residents are protected from harm and their privacy and dignity is respected. The home must conduct their DS0000024441.V340358.R01.S.doc Timescale for action 25/07/07 2. OP27 14 01/08/07 3. OP9 13 (2) 30/05/07 4. OP29 19 Schedule 2 12(4)(a) 16, 23. 25/07/07 5 OP19 OP38 DO8 01/08/07 6 OP32 7, 16, 19, 25/07/07 Page 23 Manor House Christian Rest Home Version 5.2 OP19 OP26 23 business to ensure the proper provision of facilities and services and/or develop and improve them (in a timely manor) for the benefit of residents. 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 OP38 Good Practice Recommendations The home should purchase a suitable medication trolley to ensure that medication is transported around the home safely for the protection of staff and residents (in line with Royal Pharmaceutical Society Guidelines). The home should introduce person centred care planning to evidence the individual outcomes for each resident. The Registered Manager should receive appropriate supervision and appraisal to ensure they are supported in their role for the benefit of the residents and staff. The facility for washing and disinfecting commode pots should be mended as a matter of urgency. This will limit opportunities for cross infection and promote health and safety for the benefit of residents and staff. 2. 3. 4. OP7 OP36 OP26 OP38 Manor House Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Christian Rest Home DS0000024441.V340358.R01.S.doc Version 5.2 Page 25 - 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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