Inspection on 04/10/06 for Manor House Nursing Home

This inspection was carried out on 4th October 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Manor House Nursing Home 02/03/09

Manor House Nursing Home 12/03/08

Manor House Nursing Home 06/02/06

Manor House Nursing Home 20/11/05

Manor House Nursing Home 08/02/05

Manor House Nursing Home 12/08/04

Manor House Nursing Home 26/02/04

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

CARE HOMES FOR OLDER PEOPLE Manor House Nursing Home Merton Nr Bicester Oxfordshire OX25 2NF Lead Inspector Delia Styles Unannounced Inspection 4th October 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Manor House Nursing Home DS0000042340.V314303.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 Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor House Nursing Home Address Merton Nr Bicester Oxfordshire OX25 2NF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7723 7071 info@mhnh.com European Care (UK) Limited Mrs Dinalee Rodriguez Care Home 102 Category(ies) of Dementia - over 65 years of age (102), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (102) Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Two unnamed residents under the age of 65 may be admitted to the home at any one time. The home has four named individuals who, on admission, were under the age of 65. The total number of service users to be accommodated at any one time must not exceed 102. 6th February 2006 Date of last inspection Brief Description of the Service: The Manor House Nursing Home is situated in a quiet rural location, within visiting distance of Oxford, Aylesbury and Banbury, and close to the market town of Bicester. It is easily accessible from the M40. It is set in over four acres of gardens and lawns, overlooking open countryside, with a small lake, pond and fountains. A landscaped enclosed courtyard has been created with a water feature. The original house is a 16th century manor house that has been considerably extended. The accommodation is provided on two floors and most rooms are single, en-suite. There are a few shared rooms. The home is divided up into four lodges, North, West, East, and Garden, each with its own complement of communal areas and staff. The Manor House Nursing Home is home to 102 frail older people, who require nursing care, and some require specialist care for various forms of dementia The fees for this home range from £650 to £850 per week. Manor House Nursing Home DS0000042340.V314303.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 that started on October 4th. The inspector arranged with the manager to return to the home on the morning of October 5th to complete some of the standard assessments. This is a large home and so two days were allocated to enable the inspector to look at all the key standards in sufficient detail. Detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection, was also taken into account when compiling this report. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. A total of 5 comment cards was received from Relatives/visitors and 3 from GP’s who provide medical care to residents. A comment card was also received from the consultant psychogeriatrician who visits the home monthly to review residents’ mental health care. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Verbal feedback was given to the manager of the home at the conclusion of the inspection visit. The inspector would like to thank the manager, residents and staff for their time and assistance during the visit. What the service does well: The home is well managed and the staff work well together, so that there is a relaxed and friendly atmosphere. Although a large home, each of the four ‘lodges’ provide a personalised approach to residents’ care and it is evident that the staff know and respect residents’ individual preferences about their care and how they spend their day. Relatives’ comments were very positive about the staff: ‘the staff in my opinion do their very best for the residents, are very friendly and helpful’; ‘All nursing, caring and social staff have been caring and conscious of my [relative’s] needs during my visits and to my knowledge when I’m no there. In some cases they have gone beyond the call of duty’. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 6 The home is committed to providing staff training and all staff have the opportunity to undertake relevant training courses that in turn help staff to improve the standard of care for residents. The range of activities is excellent, with dedicated activities staff to arrange individual and group activities and social events that provide residents with a variety of options to for activities both in the home and the wider community. The home and grounds are very well maintained and provide plenty of space for residents to enjoy in safety. What has improved since the last inspection? What they could do better: Further improvements could be made to residents care records by providing an index to the various sections, so that it is easier to find the current information about the residents care needs. The daily statements written by staff could be more specific if they referred to the numbered care plans. The Medication Administration Record (MAR) system would be better if all the record sheets were printed by the pharmacy: if a resident has a lot of medicines, staff have to hand-write additional instruction pages and this has a potential for errors and is time-consuming for staff. Residents room doors must not be wedged or held open because this puts residents and staff at risk in the event of a fire: closed doors are intended to slow the spread of smoke and flames for the protection of residents. If residents want to keep their doors open, or if they need frequent staff observation, the home should fit suitable automatic door closers that will close when the fire alarm sounds. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 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 Nursing Home DS0000042340.V314303.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 Nursing Home DS0000042340.V314303.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3. Standard 6 is not applicable, as intermediate care is not provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives have good information about the home in order to make an informed decision about whether the home is right for them. Each person’s needs are identified and planned for before they move into the home. EVIDENCE: The home has updated its Statement of Purpose and service user guides. Residents and their representatives can also access information about the home on the company’s Internet website. New residents are given a ‘Home Pack’ – the homes brochure, service user guide, the terms and conditions and a contract – with all the information about the home and facilities. The inspector noticed that the homes information does not include reference to the fact that the Commission undertakes regular inspections of the home and that the most recent inspection report about the home is available in the reception hall. This should be amended. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 10 The pre-admission assessment information for a sample of five recently admitted residents was looked at. The European Care paperwork that has been introduced since the last inspection gives a comprehensive assessment of people’s care needs and is a good basis on which staff can start to prepare care plans that will accurately describe the actions staff need to take to meet residents assessed care needs. Information from relatives (‘Getting to know you’) and from other health and social care professionals contribute to helping the manager when she visits prospective residents to assess whether the home will be able to meet their care needs. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system gives staff the information they need to satisfactorily meet the care needs of the residents. The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear and comprehensive arrangements in place to ensure that residents’ medication needs are met and regularly reviewed. Personal support to residents is offered in a way that promotes and protects their dignity and independence. EVIDENCE: A sample of 6 residents’ care records was examined and these were of a good standard. They included comprehensive risk assessments and copies of additional services on admission. There were good records of relatives’ involvement in discussing residents’ care needs. There was evidence that residents are referred for specialist medical care where necessary. Three GPs from the local Medical Practice visit weekly and a clinical Psycho geriatrician visits monthly. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 12 The doctors’ comment cards showed that they were satisfied that the home communicates well with them although one person felt that there were ‘occasionally’ difficulties in communicating with staff whose first language is not English. However, the same person wrote that ‘many nursing and care staff are excellent in handling residents with mental health care needs’. The inspector considered that the system of care planning could be further improved by staff making more specific comments, linked to the numbered care plans, when writing the ‘daily statements’. Also, an index for the residents’ care files would help locate the information in the various sections more easily. The inspector looked at the medications in two of the four lodges and found that they were well organised and correctly stored. The local medical practice pharmacy supplies medication in a lightweight pre-filled packaging system. Since the last inspection, the home has set up a contract with a licensed waste disposal company to collect and dispose of unwanted medications as legally required. The inspector made some recommendations about the Medicine Administration Records (MAR) pages; namely that if staff have to add handwritten alterations to the MAR these should be written out clearly and should not contain abbreviations. The maximum dosage for variable amounts of medication, such as Paracetamol, that may be given in any 24-hour period should be stated. Where the list of prescribed medications for a resident is extensive, the pharmacist should be requested to provide a 2nd printed sheet: currently the pharmacy provides only one MAR page per resident and staff have to handwrite any additional ones. This is time-consuming for staff and has the potential for them to make mistakes when transcribing medication orders that could result in a resident receiving the wrong medication. There were some inconsistencies in the way staff used the code letters on the MAR page to show the reason for a resident not receiving a prescribed medicine. Staff should always use the agreed code letters so that the doctor is aware of any specific problems for the resident that results in them not taking their medication. The inspector observed that staff were polite and respectful when talking with residents and that they were mindful of to protect residents’ privacy and dignity when assisting them with personal care. The staff were noted to knock on residents’ room doors before entering. Shared rooms have portable screens to give privacy when providing personal care for residents. Manor House Nursing Home DS0000042340.V314303.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a varied range of activities within the home and in the community that are tailored to the needs of residents. Meals and mealtimes are a social occasion for residents and the home’s chef and staff team work together to make sure that residents are able to enjoy the food they prefer. Visitors are welcomed into the home and they are encouraged to contribute their views about the care and facilities provided for residents. EVIDENCE: The home has a comprehensive programme of activities that is advertised in all the units. Though short of one activity co-ordinator (interviews for a new staff member had just taken place), the co-ordinators and staff were maintaining a full programme and were busy preparing for a Halloween party for the end of the month. Emphasis is placed on celebrating traditions such as Halloween, Bonfire Night, Valentines Day etc. and resident’s birthdays, to maintain a social calendar and opportunities for families and friends to join with residents in these events. Each resident’s care record included a ‘social activities log’ that described the activities they had enjoyed. Local Church of England clergy visit the home weekly to lead services and there are monthly Roman Catholic services. Residents can also attend church services at local places of worship. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 14 The home has a mini bus that enables small groups of residents to go out to local shops and places of interest. The home has created a second sensory room that is enjoyed as a relaxation area for individual or small numbers of residents. The gardens provide a safe outside area for residents to walk and enjoy outside. The home provides a free transport service to and from Oxford on Tuesdays and Thursdays each week for relatives who want to visit. The staff are from a wide range of different ethnic and cultural backgrounds, in comparison to residents. The manager described the work done to ensure that staff are aware of the cultural expectations and beliefs held by staff and residents from different backgrounds. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Lunchtime (from around 1 to 2 pm) was a leisurely, relaxed mealtime, with staff assisting residents who needed help at the dining tables, individual tables or in their own rooms. Those residents who needed soft food, had their pureed food served attractively with the individual portions of vegetable and meat puree. Residents were offered extra portions of courses. The menus show a wholesome balanced diet. The chef is reviewing the menus and personally checks with residents, relatives and staff about residents’ preferences. He is aiming to increase the amount of fresh seasonal foods in the menus. In the afternoon prepared fresh fruit is taken around the lodges for residents to enjoy. Manor House Nursing Home DS0000042340.V314303.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system but relatives and residents’ representatives need further information about how to raise any concerns. The manager and staff have a good understanding of adult protection issues so that residents are protected from abuse. EVIDENCE: Four of the 5 Relatives’ comment cards indicated that they were not aware of the homes complaints procedure. One of the respondents stated that they were not aware, but had had to make a complaint. One relative said that they found the manager difficult to contact and had not had a response to a handdelivered letter. The home’s Statement of Purpose includes the complaints procedure and in the Internet website information. The inspector recommends that relatives are reminded about how to bring complaints, concerns and compliments to the managers’ attention and the role of the unit leaders and deputy manager in receiving complaints. There are regular relatives meetings and relatives are invited to meet with the manager individually if they have any concerns to discuss confidentially. The manager had received no formal complaints in the past 12 months. One complainant has contacted the Commission with information concerning a complaint made to the service last year. There is evidence that the home thoroughly investigated an allegation of abuse made by a resident in October 2005 and this included referral to the Adult Protection team. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 16 All staff receive training in Adult Protection issues as part of their induction and in regular update sessions. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and grounds are well maintained. The home provides aids and equipment to meet the care needs of the residents. The home is clean, tidy and smells fresh. EVIDENCE: A programme of repainting and refurbishment over recent months has created a lighter and brighter environment. Light coloured laminate-look flooring has replaced carpeting in the corridors, sitting rooms and dining rooms. The home was clean and fresh smelling with the exception of one corridor area before lunch, but this may have been because at that time residents were getting up and rooms had yet to be cleaned. The high standard of cleanliness and tidiness that is maintained is commendable, especially given the high dependency of many of the residents in the home. The housekeeping team have a checklist of tasks that they personally sign when completed. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 18 One resident’s large armchair had damage exposing the foam. This should be repaired or the chair replaced so that the chair can be properly cleaned. The large basement laundry area was tidy, but the floor surface is worn and cracked and should be re-sealed or replaced to enable it to be effectively cleaned. The manager said this work is being planned. The inspector noticed that there were pots of barrier creams in two toilets (7 and 8), one of which had no lid. The inspector concluded that staff are using the same pots of cream for any residents who are receiving personal care in these rooms. This practice should stop, as there is a risk of cross-infection and contamination between residents sharing creams and residents should have individually prescribed supplies. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff meet residents’ care needs. The arrangements for the recruitment and induction of staff are good and aimed at protecting residents and appointing staff who will deliver a good standard of care. The service ensures that all staff receive relevant training with the aim of improving care for residents. EVIDENCE: The copy of rotas seen showed that the staffing numbers and skill mix for each unit are consistent and appear to meet the assessed needs of the residents. The home does not use agency staff. The home employs activities workers and a receptionist. Feedback from relatives and visitors both in comment cards and to the inspector on the day, was very positive about the staff – ‘they do their very best for the residents, are very friendly and helpful’; ‘all nursing, caring and social staff have been caring and conscious of my [relative’s] needs during my visits and to my knowledge when I’m not there. In some cases they have gone beyond the call of duty’; ‘Carers are polite and welcome families’. Two of the 5 Relatives/visitor cards stated that they did not feel there were always enough staff - one mentioned weekends and another that staff were not always available in the lounge rooms. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 20 The duty rosters show that the same allocation of nursing and care staff is made every day of the week. The inspector noted that a member of staff was present in sitting rooms during the afternoon and could not substantiate the relatives’ opinions on this occasion. A sample of staff files was examined and showed that the home has robust recruitment policies and practices to ensure that residents are protected by having suitably screened and trained staff employed to care for them. The system of filing of information in the staff records should be improved to make it easier to access information and to have an effective checklist of when information has been requested and provided. The home has a high proportion of staff who are nurses undertaking ‘adaptation’ courses to prepare them to work in the UK as registered nurses. Over 50 of care staff have achieved National Vocational Qualification (NVQ) at Level 2 or above. Staff spoken with said they enjoy working in this home and appreciate the opportunities they have for training and development. Unit leaders have additional training and supervision responsibilities for staff in their teams. The unit leaders and manager are undertaking a course in palliative care at a local independent hospice. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements meet the needs of the service and the quality assurance system includes the views of relatives and staff about how the service can be improved. EVIDENCE: The manager has achieved the formal management qualifications for her role and clearly is skilled and experienced in leading the staff team. She has a deputy (on holiday at the time of this inspection) and each unit leader has delegated managerial responsibilities. The home is well managed and there are clear lines of accountability in the staff team. European Care undertakes regular internal audits and sends out monthly ‘Satisfaction surveys’ to 10 of residents and their relatives each month as part of their approach to ensuring that standards of care and the facilities are Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 22 maintained. The manager said that the most recent satisfaction survey analysis has just been completed, but as at the last inspection, the results have not yet been circulated to residents and their representatives. It is again recommended that the results of the most recent survey are published and a copy sent to CSCI. The home also has a quarterly newsletter that features life and work in the home and is informative and well produced. The inspector discussed the home’s financial and accounting system with an administrator and found that it is in good order, with a clear audit trail allowing residents and their representatives to have accurate information see the receipts for any small purchases made on residents’ behalf. The company’s head office deals with accounts and invoicing. The inspector checked the Fire Safety log and accident records found these to be up to date. When visiting the Garden Lodge, the inspector noticed that all the residents’ room doors were propped open. Whilst accepting that very dependent residents may require frequent observation or assistance, room doors must not be held open as this will compromise the safety of residents and staff in the event of a fire, because the intended barrier to smoke and flame spread provided by closed doors is removed. The home should fit suitable automatic door closers with the fire officer’s approval, so that the doors can be kept open but will close when the fire alarm sounds. The regional manager and home manager confirmed that this would be done as soon as possible. Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 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 3 X 3 X 3 X X 2 Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP38 Regulation 23(4) Requirement Residents’ room doors must not be wedged or propped open. Suitable automatic door closers should be fitted, following the advice of the Fire Rescue service. Timescale for action 30/11/06 Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 25 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. Refer to Standard OP1 OP7 Good Practice Recommendations Provide information about how residents and their representatives can access the most recent CSCI inspection report for this service. Further improve the care plans/records by indexing the file sections and by making the daily statement entries more specific to the care needs/problems listed in the care plans. * Residents’ additional MAR sheets should be printed by the dispensing pharmacy * Where staff have to hand-write amendments to MAR instructions, they should not use abbreviations and should include instructions provided by the prescriber/pharmacist, such as the maximum dosage in any 24 hour period of any medication that may be given ‘as required’ or with variable dose. * Staff should use the listed code letters consistently to indicate the reason for omitting a prescribed medication dose. Ensure that residents and their representatives are aware of the homes complaints procedure and how to share concerns, complaints (and compliments) with the home. Repair or replace the damaged armchair identified during the inspection. * Repair or resurface the laundry room floor with an impermeable material that can be easily cleaned. * Discontinue the practice of using shared containers of barrier creams: residents should have individually prescribed supplies. Improve the organisation and filing of staff files so that current information is easily located. It is recommended that the results of the residents’ satisfaction survey carried out last year should be published and a copy sent to the inspector. 3. OP9 4. 5. 6. OP16 OP19 OP26 7. 8. OP29 OP33 Manor House Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Nursing Home DS0000042340.V314303.R01.S.doc Version 5.2 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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