Inspection on 09/11/06 for Manor II

This inspection was carried out on 9th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 II 08/01/09

Manor II 01/05/08

Manor II 04/06/07

Manor II 08/06/06

Manor II 30/09/05

Manor II 25/05/05

Manor II 24/01/05

Manor II 31/08/04

Manor II 23/06/04

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

CARE HOMES FOR OLDER PEOPLE Manor II 205-207 Hainault Road Leytonstone London E11 1EU Lead Inspector Kristen Judd 9 11 & 13 th th th Unannounced Inspection November 2006 09:55 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 II DS0000058844.V312079.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 II DS0000058844.V312079.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor II Address 205-207 Hainault Road Leytonstone London E11 1EU 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) 0208 539 0079 www.aermid.com Aermid Health Care Limited *** Post Vacant *** Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2006 Brief Description of the Service: Manor II is registered to provide care for up to 20 elderly people with dementia, both male and female. At the time of inspection there were 11 residents in the care home. Accommodation comprises 14 single bedrooms and three doubles, a lounge, dining room and conservatory, which is also the designated smoking area. The home is situated in Leyton with good transport facilities to local shops and amenities. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced took place over three days. This inspection follows up requirements from the unannounced inspection held on 8th August 2006.The inspectors spoke with service users, staff and relatives. The acting manager was present on the third day of inspection. There have been 24 requirements and 2 recommendations made following this inspection. Additionally an immediate requirement was made with regard to the laundry facilities. An enforcement notice will be served regarding the administration of medication. An unannounced inspection gives the Commission an opportunity to assess the home against the National Minimum Standards applicable to the service without the home having notice of the visit. A number of requirements were made at the last inspection 7 of which have not been met and have been restated in this report with a new timescale for compliance. Unmet requirements impact on the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. Verbal feedback was given to the acting manager. The inspector wishes to thank the staff and service users for facilitating this unannounced inspection. A feedback card was left for completion. What the service does well: What has improved since the last inspection? What they could do better: This home has and several acting managers, which has not provided consistency for staff or service users. There are serious concerns raised within this report and this inspection has resulted in an enforcement notice, and an immediate requirement to be issued and 23 requirements being made 7 of which are outstanding. The registered person needs to address all of these issues as a matter of urgency. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 6 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 II DS0000058844.V312079.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 II DS0000058844.V312079.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): 1,2, 3 & 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service user guide for the home requires further clarification to provide accurate, up-to-date information for prospective residents or their representatives about the services provided. EVIDENCE: The service user guide dated October 2006 however the inspector noted that it still does not include a summary of the complaints procedure or service users’ views of the home and the terms and conditions of the home. These are important issues for service users. The document does make reference to these issues however the National Minimum Standards clearly state that this information must be included in the guide. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 9 The inspector examined service user files, which indicated that there were, signed contracts in place. The inspector was informed that there have been no new admissions into the home since the previous inspection. As such standard three could not be tested to evidence that service users needs are assessed appropriately prior to admission. As such this requirements will be carried forward with a new date for compliance to be tested at the next inspection. This is therefore not deemed an outstanding requirement. The inspector examined several files during the three days of inspection and was satisfied that the current assessed needs of the service users could be met. Most care plans have been improved and focus on strengths of service users as well as needs. The home does not provide intermediate care. If, at a future date, the registered provider should wish to provide such care, consideration would need to be given to staffing levels, appropriate staff training and the provision of dedicated space for this purpose. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Progress has been made with regard to the service users care plans to ensure that all care needs will be met. However it was the inspectors view that medication was not being accurately administered; this must be addressed as a matter of urgency. Staff must be fully trained and competent before being permitted to administer medication. EVIDENCE: The inspector examined several care plans during the three days of inspection. The inspector acknowledges that the new format has greatly improved. Care plans seen clearly indicated service users needs, service users strengths and how staff should meet needs. One of the files examined did not contain the new format; the acting manager confirmed that this piece of work had not been completed. As such there remains an outstanding requirement. The inspector was satisfied that care plans were being evaluated and reviewed on a monthly basis. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 11 There has been an improvement in the risk assessments in place, however it must become the practise to implement risk assessments following incidents. The inspector examined one service user file that indicated verbal aggression. Daily recordings highlighted concerns about aggression both to staff and other service users. However no risk assessment was in place. The general logbook identified that x had a fall on 02/11/06 at night; records indicated a head injury and that the fall not observed. There were no records to indicate that there was appropriate follow up action taken given that a head injury was sustained. On the first day of inspection it was noted that the medication keys left on top of medication trolley. A random medication was checked was conducted on day one of this inspection. One service user had been administered ‘Zopiclone’ PRN written up to taken if required at 21:00. The medication not signed for but missing from blister pack. The staff member responsible for medication had administered the medication and signed record in front of inspector. The inspector asked the staff member to explain why the PRN had been given. The staff member could not explain, the staff member was also asked to asked to read (aloud) the instructions for administering the medication, however was unable to read the instructions. The staff member was unable to describe what the medication was for, or the reasons for administering it. This is extremely concerning. Further medication checks were undertaken it was noted that for two service users Senna 1 or 2 tablets to be taken, medication was signed for but records did not indicate the quantity administered. Eye drops for one-service users did not indicate the date of opening and were not appropriately stored. Another service user prescribed Neoclarityn 5mg mane. 13 tablets were dispensed on 30/10/06.The medication records indicated that medication commenced on 31/10/06 signed as given on 11 consecutive days and there were three tablets counted in box which totals 14 tablets which indicates an error. On the second day of inspection another check was conducted, it was noted that medication was not signed for two service users the day before. Medication was missing from the blister packs. This is concerning and the Commission will be taking enforcement action to ensure that satisfactory improvement is made for the wellbeing and protection of service users. During the second day of inspection the district nurse attended to administer flu injections to service user. The inspector noted that a room on the ground Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 12 floor was being used as a treatment room. This room was occupied at the time of inspection. This is unacceptable practise. Staff must ensure that any medical examination or treatment is provided in service users own rooms. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some work has been done to introduce activities into the home, however activities are still limited which restricts choice to service users. Service must be offered choice at meal times. EVIDENCE: Staff continue to take responsibility to arrange and facilitate activities in the home. As such activities can only be offered once staff have finished relevant tasks such as personal care. During the inspection no activities were undertaken, the inspector noted on the 11/11/06, which was the second day of inspection, staff did not acknowledge the importance of the day and the inspector had to suggest that service users might wish to watch the Lord Mayors Parade and observe the two-minute silence. The inspector acknowledges that throughout this shift staff were extremely busy. However once the television was turned to the service, the service users began discuss the programme about the war, comment on the parade and Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 14 interacted with each other. Service users observed the two-minute silence and those able stood up as a mark of respect on their own accord. Staff must be aware that such days are of great importance to older people and as such this day could have been made very special if there had been some forward thinking. The inspector had the opportunity to speak with a relative who was complimentary of the staff and the care provided to her mother. The relative commented that they were always made to feel welcome and had no concerns. There remains a lack of evidence of any community contact and this area needs to be developed. As highlighted in this report there remain issues with regard to staffing levels and as such this put limitations on service users being given the opportunity to access the community with staff support. The registered person should develop this area in line with service user wishes. The inspector requested to see the menus in place however was informed that menus had not been planned. The inspector noted that there was no choice of meal being offered although was informed that if service users did not like the option then an alternative would be offered. The inspector also observed that service users were also not given any choice with regard to beverages at mealtime. The cook records actual foods served to service users and these records indicated a varied diet. Service user on the second day of inspection appeared to enjoy the meal prepared. The cook was also observed making home made soup for tea. However there was concern with regard to the following storage and cleaning issues: The vent over the cooker required cleaning Additionally the cold-water tap required attention for ease of use. The double doors between food storage area and cooks toilet was ineffective due to placement of freezer in doorway between two areas. The chest freezer the lid was completely broken and unhinged, it was weighted down with squash bottles and cake tin but still did not fully close, the contents were therefore suspect. Standard 14 was fully met at the previous inspection. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are relevant policies and procedures in place however records must be available for inspection to be able to evidence that complaints are dealt with efficiently and in line with procedure. EVIDENCE: There are policies and procedures in place for all aspects of complaint handling that states that any complaint will be acknowledged within two days and that any complaint will be investigated, within timescales indicated. The policy also provides guidance for staff if a verbal complaint is received. There is information about how to complain on display in the home. The registered manager is responsible to investigate complaints and concerns that service users, relatives or staff may have. However at the time of inspection the complaints log could not be found. Therefore it could not be evidenced whether there have been any complaints or whether they have been investigated appropriately and in line with procedure. The organisation has now amended the Safe guarding Adults procedure that now indicates that any allegation must be referred to the Local Authority. The inspector was informed that all staff had attended Adult Protection training in July 2006 and a refreshers course was planned for December 2006. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 16 There has been one allegation since the previous inspection, which was not handled in line with procedure by the acting manager at the time. This issue has now been addressed and the service manager conducted an investigation after liaising with the local authority. Manor II DS0000058844.V312079.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There some very concerning issues noted which must be addressed. Staff in the home must all take responsibility for ensuring that the environment is maintained at a satisfactory level at all times. EVIDENCE: One the second day of inspection the conservatory area was not of adequate temperature. Service users looked cold and when spoken to indicated that they were cold. The inspector spoke with staff regarding the concerns, staff tried to move the service users to a warmer part of the home however they were reluctant. Blow heaters were put in place. When the inspector left the home the temperature was at a suitable level. The inspector acknowledges that the heating had been repaired when the inspector return to the home on the 13/11/06 however it is concerning that staff were unaware of the heating problem. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 18 It is concerning to note that there was a very large gap under the rear double glazed fire exit door (from conservatory to garden) of approximately 2-3cm’s permitting a freezing draft to enter the home. The inspector was informed that the stair lift had been out of action since (at least) 04/11/06, this date was evidenced on the call-out docket from the service company. As a result of above some service users had been moved downstairs – but four continued to have bedrooms upstairs. One of the service users was required to climb stairs to access his bedroom. The service user was suffering pain in his knees he stated that he would be happier if he could have a ground floor room whilst the stair lift was out of order. Unacceptably, no vacant ground floor room was available for the night of the inspection and staff assisted Michael to climb stairs. Neither laundry facilities (those in basement or first floor) were working. Staff confirmed that these had not been working for at least two months. In basement six black sacks of soiled laundry had been left on the floor and produced an unpleasant odour. Staff commented that laundry was taken across to other Manor for laundering. Wet laundry (clothing and linen) was drying in cellar adjacent to serious rising damp problem. One the second day of inspection staff confirmed that the facilities at the manor were being used. However there were still five bags of laundry to be done. While the inspector was present a staff member returned to the home with the laundry that had been washed however all of the bags contained wet laundry, and there were no adequate facilities for the drying of the laundry. The staff member used wheelchair to transport the laundry. The inspector issued an immediate requirement in relation to this issue. One day one of the inspection all nurse call pull cords were intentionally tied up out of reach throughout the home (bathrooms and en suites).This is unacceptable practise. The additional environmental issue were noted on day one of this inspection. Trip hazard into first floor laundry room where hall carpet had not been cut to fit or fixed. Light bulb out in ground floor gents toilet and one en suite on the first floor – staff commented had been the case for some days. Hole in door of bathroom on ground floor this compromises privacy/dignity of service users. Standards 20,21,23,and 24 were met at the previous inspection. Manor II DS0000058844.V312079.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There remain serious concerns with regard to staffing levels and competencies of some of the staff team. This potentially puts service users at risk. The registered person must ensure that staff only undertaken tasks that they are deemed competent to do so. EVIDENCE: As previously stated staff are responsible for undertaking activities with service user. The inspector noted on the second day of inspection there were two care staff on duty. Due to the high level of personal care that service users need it was difficult for an activity to be undertaken. Staff were observed as being busy throughout the shift and did not stop for individual breaks. This is concerning and staffing levels must be appropriate to ensure that activities are offered. During the inspection there was concern around ability of permanent staff to effectively communicate in English – speech, reading, and comprehension, which seriously compromise’s the welfare of service users. On day one of the inspection service users were clearly struggling to understand, and vice versa. As stated in this report there was a particular concern with regard to the staff member who was clearly unsuited to administer medication without further training. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 20 Random samples of staff files were examined and contained relevant checks as required by regulation. No new staff have been employed since the previous inspection and as such the requirement with regards to staff induction could not be assessed. Therefore this requirement has been reinstated with a new timescale. This is not deemed an outstanding requirement. The inspector was informed that the organisation is now paying staff to attend training sessions. Since the previous inspection staff have received training such as Alzheimer’s and Dementia and Adult protection. Standard 28 was met at the previous inspection. Manor II DS0000058844.V312079.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 34, 36,37 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The content of this report, which includes unmet requirements from the last inspection, continues to reflect poorly on the conduct and management within the organisation. EVIDENCE: There is currently no registered manager in place. The acting manager at the time of inspection had clearly made some improvements in particular in updating the service users care plans. However this home has and several acting managers, which has not provided consistency for staff or service users. There are serious concerns raised within this report and this inspection has resulted in an enforcement notice, and an immediate requirement to be issued and 24 requirements being made 7 of Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 22 which are outstanding. The registered person needs to address all of these issues as a matter of urgency. Samples of supervision records were examined during the inspection, which was not in line with regulation. This has clearly been due to management changes however is concerning. The evidence in this report indicates that there remain concerns with regard to the skills and competencies of particular members of staff. Given the content and concerns raised in this report it remains an outstanding requirement that the registered person must maintain a thorough system for monitoring and improving the quality of care provided in the care home as a matter if urgency. The acting manager confirmed that financial issues have been addressed and that monies are accessible on a daily basis. Finances checked were deemed correct. There have some improvements noted in the recording in particular care plans and risk assessments. However there are still outstanding issues in particular complaints, medication, and supervision records. Requirements have been made against individual standards. The accident records were seen, these are separate sheets and are not numbered, as such records can be added. The registered person must implement a system for recording such records in order. The inspector was informed that the stair lift had been out of action since (at least) 04/11/06, this date was evidenced on the call-out docket from the service company. The Commission were not notified of this issue. The inspector also noted that there were dates of birth on a list of service users on display in communal areas of the home. Such information is confidential and should be removed. During the inspection conducted on the evening of the 9/11/06 there was a bedroom door propped open with walking frame. A further room (room 1) outer door propped open with a shower seat, inner door closed, however shower seat posed obstruction. COSHH was being stored in cupboard (with glazed door), which was unlocked and not lockable due to the lock having been removed. Other COSHH items stored in cupboard in kitchen, also unlocked with key in lock. The responsible person must ensure that suitable arrangements are made to secure COSHH products at all times. Standard 35 was met at the previous inspection. Manor II DS0000058844.V312079.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 1 3 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 3 1 x x 2 x x 2 1 STAFFING Standard No Score 27 1 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 3 x 2 1 2 Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 5.1 Requirement The registered person must ensure that the Services Users’ Guide to provide accurate up-todate information, to be in a format suitable for the residents and to include all the information listed in standard 1 of the NMS and regulation 5 to the Care Homes Regulations 2001. (Timescale 30/11/05 not met) The registered person must ensure that service user needs are appropriately assessed prior to admission. The registered person must ensure that service users care plans accurately indicate all of the assessed needs and how those needs are to be met. (Timescale 31/08/06 not met) The registered person must ensure that risk assessments be implemented when risk are indicated. The registered person must DS0000058844.V312079.R01.S.doc Timescale for action 31/12/06 2. OP3 14.1(a) 31/12/06 3. OP7 15.1 31/12/06 4. OP7 13.4(c ) 31/12/06 5. Manor II OP8 12.1 31/12/06 Page 25 Version 5.2 6. OP10 12.4(a) 7. OP12 16.2(n) 8. 9. 10. OP12 OP15 OP16 12.2 16.2 22.3 11.. OP19 23.1 12. OP19 23.2 13. 14. 15. OP22 OP25 OP27 23.2 (a) 23.2(p) 18.1(a) ensure that appropriate action is undertaken following accidents and actions are clearly recorded. The registered person must ensure that staff must ensure that any medical examination or treatment is provided in service users own rooms. The registered person must ensure that there are suitable and appropriate activities undertaken The registered person must ensure that service users are offered choice on a daily basis. The registered person must address the issues raised in the report. The registered person must ensure that a record of complaints is available for inspection with detailed information of the investigation and any actions taken. The registered person must ensure that the issues raised in this report are addressed to ensure that the home is fit for purpose. The registered person must investigate the visible damp problem in the basement and forward a full report of works that need to be undertaken and timescale to make suitable repairs. The registered person must ensure that service users can access call systems at all times. The registered person must ensure that the home is adequately heated at all times. The registered person must ensure that all staff are competent to meet the assessed needs of service users. (Timescale of 15/11/05 not 31/12/06 31/12/06 31/12/06 31/12/06 31/12/06 31/12/06 31/12/06 31/12/06 31/12/06 31/12/06 Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 26 16. OP27 18.1(a) met) The registered person must 31/12/06 ensure that at all times staff are present in such numbers that are appropriate for the health and welfare of the service users. (Timescale of 31/07/06 not met) The registered person must ensure that all staff undertake induction training in line with the National Minimum Standards. The registered person must appoint a suitable manager and an application be forwarded to the Commission for registration. The registered person must establish and maintain a system for improving the quality of care provided in the care home. (Timescale of 31/08/06 not met) The registered manager must ensure that all staff in the home be appropriately supervised at least six times a year. (Timescale of 31/08/06 not met) The registered person must ensure that the Commission for Social Care Inspection inform of all incidents under regulation 37 of the Care Homes Regulations 2001. (Timescale of 31/07/06 not met) The registered person must ensure that all records are maintained in line with the Data Protection Act 1998. The registered parson must ensure that all COSHH is appropriately stored at all times. The registered person must ensure that fire doors are not propped open but fitted with DS0000058844.V312079.R01.S.doc 17. OP30 18.1(c) 31/12/06 18. OP31 8.1 31/01/07 19. OP33 24.1 31/12/06 20. OP36 18.2 31/12/06 21. OP37 37 31/12/06 22. OP37 17 31/12/06 23. 24. OP38 OP38 23.2 23.4 31/12/06 31/12/06 Manor II Version 5.2 Page 27 ‘Dorgaurds’ 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 OP13 OP37 Good Practice Recommendations It is recommended that the registered person develop the community links in line with service users wishes. It is recommended that accidents be recorded in numerical order. Manor II DS0000058844.V312079.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 II DS0000058844.V312079.R01.S.doc Version 5.2 Page 29 - 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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