Inspection on 22/08/07 for Manor Lodge

This inspection was carried out on 22nd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Lodge 25/04/06

Manor Lodge 06/09/05

Manor Lodge 04/04/05

Manor Lodge 17/08/04

Manor Lodge 14/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Manor Lodge 32/34 Manor Road Harrow Middlesex HA1 2PD Lead Inspector Judith Brindle Key Unannounced Inspection 22nd August 2007 08:55 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 DS0000017549.V342942.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. DS0000017549.V342942.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Lodge Address 32/34 Manor Road Harrow Middlesex HA1 2PD 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 8427 3211 020 8868 8375 R.M.D Enterprises Limited Mrs Laura Silvia Fernandes Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places DS0000017549.V342942.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2006 Brief Description of the Service: Manor Lodge is a care home providing personal care and accommodation for 16 older people. It is owned by R.M.D Enterprises. The home is located in a quiet residential road, within a few minutes walk from Kenton and central Harrow, where there are numerous shops, restaurants, cafes, banks, and other amenities, and facilities including train, and bus public transport facilities. The home was opened in 1990. It is a detached building, in a residential area. There is parking for several vehicles at the front of the home. The home has 14 single bedrooms, 4 of which have en-suite facilities. There is one shared bedroom. The care home has a passenger lift. The home has an enclosed well-maintained garden at the rear of the property, which is easily accessible. Information about the service provided by the care home is accessible to people living in the care home and from the provider. Information about the fees is available from the owner, and is recorded in each resident’s statement of terms and conditions documentation. DS0000017549.V342942.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place during a day in August 2007. There was one vacancy at the time of the inspection. The purpose of the inspection was to spend time talking with people using the service, assess 24 National Minimum Standards (including key Standards), and to follow up and assess as to whether requirements and recommendations from the previous inspection had been met. The inspection included a tour of the premises, and inspection of resident’s care plans, staff personnel records, medication storage and administration systems, and inspection of a variety of other records. The inspector also spent a significant part of the inspection talking with staff, and people using the service, and observing interaction between residents and staff. Observation was also a significant tool used in the inspection process. Information and evidence was also obtained from the home since the last key inspection in 2006, which included notification of significant events affecting people using the service. The registered manager was present during the inspection, and a provider, Mr Merali was present during part of the inspection. Staff kindly provided all the information, and documentation requested by the inspector during the inspection. Requirements from the previous inspection were judged as having been met. The registered manager has received the Annual Quality Assurance Assessment (AQAA) documentation from the Commission for Social Care inspection (CSCI) and is in the process of completing this document. The inspector thanks all the people living in the care home, and the staff for their assistance during the inspection process. What the service does well: The care home has a very welcoming atmosphere. Residents live in a homely environment. People living in the home were very positive about the care home and staff, and confirmed that they were all happy living in the home, and were supported to make choices. A person using the service spoke of being ‘happy’ in the home and of not wanting to be ‘anywhere else’ People using the service spoke highly of the meals provided. DS0000017549.V342942.R01.S.doc Version 5.2 Page 6 Residents’ contact with relatives and others is fully supported and enabled by the care home. Visitors generally spoke very positively about the care and support provided for his/her relative by staff. The registered manager is experienced, and she ensures that there is liaison with healthcare professionals and other specialists as and when required/needed by the residents. Observation and talking to staff indicated that staff were aware of resident’s individual needs and interacted in a respectful and sensitive manner with people using the service. What has improved since the last inspection? What they could do better: 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 DS0000017549.V342942.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. DS0000017549.V342942.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 DS0000017549.V342942.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 and 3 (6 is not applicable) People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for prospective service users to have the information that they need to make an informed choice about where to live. The format of this documentation could be developed to improve its accessibility to people using the service. Arrangements are in place to ensure that prospective resident’s needs are assessed. EVIDENCE: The care home has accessible documentation, which includes a statement of purpose and a service user guide. The registered person could examine ways of developing the format of the service user guide to improve its accessibility to people using the service who have difficulty in reading due to varied communication needs. DS0000017549.V342942.R01.S.doc Version 5.2 Page 10 The care home has an admissions policy. Care plans of people using the service who had been recently admitted to the home confirmed that the manager had carried out a comprehensive initial assessment of the resident. There should be more recorded evidence of the participation and involvement of people using the service and/or their relatives in this assessment process. Evaluation of personal care needs, sensory needs, medication usage, interests, dietary needs, social contacts, and mobility needs is included in the assessment process. A resident spoke of her relatives visiting the care home prior to her admission, she confirmed that she did not visit the home, due to being admitted from hospital. Another person using the service spoke of visiting the care home with relatives prior to his/her admission. DS0000017549.V342942.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9, and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that all people using the service have a plan of care, which sets out their health, personal and social care needs. The content and the format of care plans could be improved to indicate participation from people using the service. Residents are treated with respect. Risks and guidance to minimise identified risks could be better documented, to help people using the service to lead the life that they want. Medication is stored and administered safely EVIDENCE: All the residents have a plan of care. Six care plans were inspected. These included some clear guidance to ensure that staff meet the assessed needs of the people using the service. The care plans are reviewed monthly, and changes in need were documented. The care plan should be a ‘working document’, and be more person centred, and include detail of how each resident’ aspirations, are to be met. The format of the care plans should DS0000017549.V342942.R01.S.doc Version 5.2 Page 12 include evidence of a variety of different and creative methods to help people who use the service to contribute to the development of their care plan, and the ongoing process of review. The registered manager should also examine and develop more ways of ensuring that all staff, relatives/significant others (if agreed by the resident) are involved in the care plan and its review. A resident spoke of choosing her own clothes and of choosing what time to go to bed. Daily’ and night resident’s progress records are documented. Staff were observed interact with residents in a sensitive and respectful manner during the inspection. People living in the care home have access to a telephone. Risk assessment documentation indicated that some risks in some care plans such as risk of falls, moving and handling risk, and risk of developing pressure sores were assessed. There could be further development in risk assessments to include other areas of potential risk, which are managed positively to help the people using the service to lead the life that they want. From speaking to residents, staff and inspection of records it was evident that people living in the home are having the support and care they need to meet their personal care needs. Health needs are monitored and appropriate intervention taken. The manager reported that there are no residents who have pressure sores. Records confirmed that residents have their health needs monitored, and have access to care and treatment from a variety of healthcare professionals. These include GP appointments, optician, dentist, chiropody care and treatment. Residents as needed, access additional specialist support and advice. Residents’ weight is monitored. A resident said that ‘if I am not well staff get the doctor’. The care home has a medication policy/procedure. The medication storage and administration systems were inspected. Medication is stored securely. The registered manager reported that staff receive training and assessment to ensure their competency prior to them administrating medication to people using the service. A completed assessment was available for inspection. This document should be dated. DS0000017549.V342942.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): Standards 12,13,14 and 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the care home have the opportunity to take part in a variety of preferred activities, but these could continue to be further developed. Arrangements are in place to enable people living in the care home to maintain contact with family/significant others, as they wish. People living in the care home have their rights respected Arrangements are in place to ensure that people using the service choose meals, and are varied and wholesome, and meet the dietary needs of the residents. EVIDENCE: Records confirmed that people living in the home had the opportunity to participate in some preferred activities. A resident spoke of enjoying reading the newspaper, another spoke of enjoying some programmes on television. Several residents spoke of enjoying the garden in warm weather. I was informed that the home had recently held a barbeque for all residents and their visitors. A resident spoke of enjoying the occasion. Another resident had recently celebrated her birthday. The registered manager spoke of some DS0000017549.V342942.R01.S.doc Version 5.2 Page 14 people using the service having recently participated in a picnic trip to a nearby lake. Records confirmed that the manager had acted in response to residents in regard to their choice of some particular leisure preferences. A person using the service spoke of regular outings with a member of her church, and of going for a walk outside the home each day. Residents spoke of having their hair ‘done’ by the hairdresser who visits the care home regularly. Other recorded activities included ball games, and exercise sessions. A resident listened to an audio book during the inspection. She spoke of being able to access these books from the mobile library. Another resident spoke of enjoying embroidery. A staff member spoke of a resident who regularly chooses to participate in household duties. Some residents spoke of there not being much to do and of ‘sitting for much of the day’. The registered person should continue to develop the variety and number of preferred activities for people using the service, including 1-1 activities. People who use the service have the opportunity to develop and maintain personal and family relationships. The registered person does not impose restrictions on visits (unless requested by the resident concerned). A resident spoke of the visitors that they received on a regular basis. Residents spoke of the visitors that they receive on a regular basis. Residents spoke of having recently gone out with their relatives. A person using the service visited a garden centre with a relative during the inspection. The visitor’s record book indicated that people regularly visited the home. Visitors who kindly spoke with me confirmed that they visited the home regularly at varying times of the day. A visitor confirmed that they are kept informed of issues that concern their relative/friend living in the care home. People using the service were observed to interact positively with each other during the inspection. The home has a menu. This recorded varied and wholesome meals. The meals for the day of the inspection were recorded on a display board located in the sitting/dining room. The cook/chef was heard to ask people using the service what they wished to choose to eat on the day of the inspection. The cook was knowledgeable of the particular dietary needs of some residents, and spoke of how she gained knowledge of the food ‘likes’ and dislikes’ of people using the service, and of the ways fresh fruit was made accessible to all the residents. She confirmed that she had achieved the required food and hygiene qualification. Residents spoke of enjoying the meals provided. This included the lunch provided during the inspection. Condiments were provided during the meal to residents, and lunch was unhurried. A resident said that the food provided was ‘out of this world’, and that the chef was ‘excellent’. Another resident spoke of the food being ‘very nice’, and of having choice. Staff were observed to encourage residents with their meal and to provide assistance when needed. DS0000017549.V342942.R01.S.doc Version 5.2 Page 15 Drinks and biscuits were offered regularly in between meals. Food eaten by people using the service is recorded. I was informed by the cook/chef that in response to a recent questionnaire completed by people using the service, least favourite meals had been removed from the menu. This is positive. DS0000017549.V342942.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the care home can feel confident that the staff team at the home know what to do if there are complaints or concerns, The home has clear guidance for staff about the procedures to be followed when a complaint is communicated or if there is a suspicion or allegation of abuse. The format of these policies could be more accessible to people using the service. EVIDENCE: The care home has a complaints policy. This is in written format, displayed in the home, and recorded in the service user guide documentation. The registered person should develop the format of the complaints procedure to ensure that it is accessible as possible to all the people using the service, including those who have difficulty in reading. It was evident from the complaints records that residents were aware of how to make a complaint, and that their complaints/’concerns’ are taken seriously. A resident said that she knew how to complain and that she would make a complaint if she needed to. A visitor communicated a complaint about the laundering of some of their relatives’ garments. The manager spoke of the action being taken to resolve the issue. This complaint needed to have been documented with details of the investigation and any actions taken. All complaints and ‘concerns’ need to be recorded. DS0000017549.V342942.R01.S.doc Version 5.2 Page 17 The home has a protection of vulnerable adults policy. Staff who spoke with the inspector were knowledgeable of the reporting and recording procedures in regard to an allegation or suspicion of abuse. The registered person should get a copy of the up to date Local Authority Safeguarding Adults policy/procedure. Records and staff confirmed that staff had received protection of vulnerable adults training. DS0000017549.V342942.R01.S.doc Version 5.2 Page 18 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): Standards 19,23 and 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, homely, clean and comfortable. The premises are suitable for the care home’s stated purpose. Residents’ bedrooms are individually personalised, and meet their individual needs. EVIDENCE: The environment of the care home provides for the individual requirements of the people using the service. The living environment is very clean, homely and generally well maintained. Residents, who kindly spoke to me, confirmed that the environment is agreeable, and meets their needs. They spoke positively of the garden facility. The forecourt of the home has parking for several cars. Bedrooms are generally personalised. Pictures, photographs and ornaments were among the items located in resident’s rooms. The manager spoke of residents being able to bring to the care home their own furniture if they wish. DS0000017549.V342942.R01.S.doc Version 5.2 Page 19 A person using the service spoke of having brought several personal items with her when she was admitted to the care home. A resident reported that she had a call bell, which was in working order. The home is clean and odour free. Soap and hand towels were located in the bathrooms/toilets inspected. A person using the service spoke of the care home being ‘spotless’. The laundry facility is located away from food storage and food preparation areas. The home has an infection control policy/procedure. A domestic staff member is employed on a part time basis. Staff were observed to wear protective clothing as and when needed. DS0000017549.V342942.R01.S.doc Version 5.2 Page 20 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): Standards 27,28,29 and 30 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home would benefit from a review of staffing numbers during some parts of the day, to ensure that people using the service have their needs met at all times. Staff receive training to ensure that they are competent and skilled in regard to carrying out their roles and responsibilities, but this could be further improved and developed. Arrangements are in place to ensure that people living in the home are supported and protected by the care home’s recruitment policy and procedures. EVIDENCE: People living in the care home spoke highly of the staff, and reported that they know them well. Staff were observed to communicate with people living in the home in an effective and sensitive manner. Comments from people using the service, about the staff included they are ‘wonderful’, and ‘very caring’, and ‘will do everything to help you’. A resident said that she felt ‘safe and secure’ in the care home. Another resident spoke of being ‘happy’ in the home and of not wanting to be ‘anywhere else’. A staff rota was available for inspection. The names of the staff on duty on the day of the inspection were recorded on a display board located in the sitting/dining room. There are generally three staff and the manager on duty DS0000017549.V342942.R01.S.doc Version 5.2 Page 21 during weekdays. There are two staff on duty at night. A part time cook/chef and a domestic staff member are also employed. Prior to the unannounced inspection, a visitor informed the Commission of Social Care Inspection that they were concerned about the number of staff on duty in the afternoon particularly in the evenings. This has been an issue raised in previous inspections. The rota confirmed that there are two care staff on duty during the afternoons. I spoke with the registered manager, and care staff about the number and kind of duties that the care staff carried out in the evenings. These duties are varied, and include ensuring that all residents have the opportunity to participate in afternoon activities, receive supper (the cook/chef is not on duty in the evenings), medication has to be administered, several residents need support with their personal care needs, and assistance with getting ready for bed. The layout of the care home is such that staff could need to work on another floor of the home particularly, when residents need support from two care staff. There are occasions for example when the two evening staff are providing care to a resident, when the sitting/dining room area is not staffed. The manager spoke of being available often after her shift particularly in the afternoon (after 4pm) to ensure that resident’s needs are met. The registered person needs to review this staffing issue and take appropriate action (i.e. provide more staffing during those hours) if needed to ensure that all residents have their needs met and are at minimal risk to their health and safety at all times. There needs to be plentiful staff at all times to support the needs, activities and aspirations of the people using the service in an individualised and person centred way. The manager still only has two shifts a week when she is meant to be supernumerary. The registered person needs to review the hours when the manager is supernumerary, linking the review to her role and responsibilities. It is strongly recommended that the registered manager has more shifts when she is not working as a shift leader and so providing care and support for residents, so as to enable her to carry out the significant number of management duties (see Standard 31). This has been an issue from previous inspections. Records confirmed that a senior staff meeting had taken place recently. I was informed that two staff had achieved an NVQ (National Vocational Qualification) level 2 care qualification, and that one staff member was planning to commence training in an NVQ 2 qualification in care. The registered manager reported that there are presently four staff employed in the care home that have nursing qualifications. The registered person should continue to ensure that all care staff have the opportunity and support to achieve an NVQ qualification in care, and so meet the National Minimum Standard (28). DS0000017549.V342942.R01.S.doc Version 5.2 Page 22 The home has a recruitment and selection policy/procedure. Three staff personnel files were inspected. This documentation included evidence that required and appropriate recruitment procedures had been carried out. The registered manager spoke of the induction that staff programme that staff receive when commencing employment. Two staff confirmed that they had received satisfactory induction training. Staff and records confirmed that staff had recently received some statutory training (i.e. moving and handling training, fire safety training). I was informed by the registered person that health and safety training, infection control training, and dementia care training was planned for staff. Records and staff confirmed that staff training including specialised training appropriate to the roles and responsibilities of staff could be further developed to ensure that all staff can meet the varied needs of the people living in the care home. DS0000017549.V342942.R01.S.doc Version 5.2 Page 23 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): Standards 31,33,35,36 and 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is competent and experienced to run the care home, but needs to complete some appropriate qualifications. Arrangements are in place to ensure that effective quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home, but there could be some development in this. Staff supervision could take place more frequently. Arrangements are in place to ensure that so far as reasonably practicable the health, safety and welfare of people using the service and staff is promoted and protected. EVIDENCE: DS0000017549.V342942.R01.S.doc Version 5.2 Page 24 The registered manager has managed the care home for several years, and has a good understanding of the needs of older persons. She is particularly caring and sensitive in understanding and meeting resident’s needs, and has a very much ‘hands on’ approach. People living in the care home spoke highly of the manager and reported that they would approach her if they had a concern. It was evident during the inspection that the registered manager was well known, and well liked by people using the service. The registered manager is aware of the need to complete NVQ level 4 qualifications in management and care, but reported that due to a number of issues that this training has been put ‘on hold’. The registered person should seek ways of ensuring that the registered manager has time set aside for achieving this qualification, and could also include ensuring that the manager has more shifts when she is supernumerary (see Standard 27), and/or employ a deputy manager. There are clear lines of accountability within the home with the owners of the care home. The owners of the care home visit it on a very regular basis. Records confirmed that there were some systems in place to monitor the quality of the service. This includes reviewing care plans and other documentation including some policies and procedures. There have been recent questionnaires supplied to residents about specific issues for example the quality of the meals (see Standard 15), and activities. An annual development plan of the service for 2007 was available for inspection. This could be further developed, and should include when the recorded objectives in regard to improving the quality of the service are to be reviewed. Records confirmed that questionnaires about views of the service had been supplied to relatives/significant others, and that these views were generally very positive. The manager spoke of plans to supply (in 2007) residents with questionnaires about the service. Residents meetings take place. Records confirmed that action had been taken in response to a residents wish to get up in the morning a little later. The registered manager had in 2006 carried out some unannounced visits to the care home and had completed a recorded proprietors ‘monthly’ report as required, but in 2007 recording of these visits was not a regular occurrence. The owner spoke of the various ways that these visits had started to be carried out by him, and were to be recorded by the manager. A partial record of a recent visit was available for inspection, but this was not comprehensive. The registered person needs to ensure that he prepare a written report on the conduct of the home following unannounced visits that take place at least monthly. No staff act as appointees for residents. Small amounts of monies are held for residents. Balances and records of two residents’ monies were inspected. Appropriate recording and monitoring of monies held by residents takes place. DS0000017549.V342942.R01.S.doc Version 5.2 Page 25 Some staff supervision records were available for inspection, but these, and information from staff did not indicate that all care staff receive formal supervision at least six times a year. There was evidence that required equipment checks are carried out. An annual electrical portable appliance test check needs to be completed. The last check was recorded as December 2006. The owner spoke of this test having been planned to take place shortly. Household cleaning products are kept securely. There were no obvious health and safety issues apparent during the inspection. Accidents and action taken to prevent further occurrence of accidents/incidents are recorded. Required fire checks of are carried out. An up to date employers liability insurance certificate was displayed. DS0000017549.V342942.R01.S.doc Version 5.2 Page 26 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 DS0000017549.V342942.R01.S.doc Version 5.2 Page 27 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 2 Standard OP16 Regulation 22 (3)(4) Requirement Timescale for action 01/11/07 01/11/07 OP27 3 OP27 4 OP31 5 OP33 All complaints/concerns from relatives/significant others need to be recorded. 18(1)(a) The registered person needs to review the afternoon/evening staffing needs, and take appropriate action (i.e. provide more staffing during those hours) if needed to ensure that all residents have their needs met and are at minimal risk to their health and safety at all times. 9 18 (1) The registered person needs to review the hours when the manager is supernumerary, linking the review to her role and responsibilities. 9 (2)(b)(i) The registered manager needs to 18(1)(ii) complete NVQ level 4 in management and care to ensure that she has the qualifications for managing the care home. 26(3)(4) The registered person needs to (5)(b) ensure that he prepare a written report on the conduct of the home following unannounced visits that take place at least monthly. DS0000017549.V342942.R01.S.doc 01/11/07 01/04/08 01/11/07 Version 5.2 Page 28 6 OP36 18(2) All care staff need to receive formal supervision (at least six times a year) to ensure that all aspects of their practice is reviewed and developed. 01/11/07 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 OP1 Good Practice Recommendations The registered person could examine ways of developing the format of the service user guide to improve its accessibility to residents who have difficulty in reading due to varied communication needs. There should be more recorded evidence of the participation and involvement of people using the service and/or their relatives in this assessment process. • The care plans should be ‘working documents’, be more person centred, and include detail of how each resident’ aspirations, are to be met. • The registered manager should also examine and develop more ways of ensuring that all staff, relatives/significant others (if agreed by the resident) are involved in the care plan and its review. There could be further development in risk assessments to include other areas of potential risk, which are managed positively to help the people using the service to lead the life that they want. The registered person should develop the format of the complaints procedure to ensure that it is accessible as possible to all the people using the service, including those who have difficulty in reading. The registered person should get a copy of the up to date Local Authority Safeguarding Adults policy/procedure. The registered person should continue to ensure that all care staff have the opportunity and support to achieve an NVQ qualification in care. Staff training including specialised training appropriate to the roles and responsibilities of staff could be further developed. DS0000017549.V342942.R01.S.doc Version 5.2 Page 29 2 3 OP3 OP7 4 OP8 5 OP16 6 7 8 OP18 OP28 OP30 9 OP31 10 OP33 The registered person should seek ways of ensuring that the registered manager has time set aside for achieving NVQ 4, and could also include ensuring that the manager has more shifts when she is supernumerary and/or employ a deputy manager. The annual development plan could be further developed, and should include when the recorded objectives in regard to improving the quality of the service are to be reviewed. • DS0000017549.V342942.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 DS0000017549.V342942.R01.S.doc Version 5.2 Page 31 - 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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