Inspection on 25/04/06 for Manor Lodge

This inspection was carried out on 25th April 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 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 Lodge 22/08/07

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 08:45 25th, 28th April 2006 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 Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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 Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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 Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 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. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout 12.5 hours during two days in April 2006. The inspector was pleased to meet, and speak with most of the residents, some relatives/visitors, a pharmacist, and several staff on duty. The purpose of the inspection was to spend time with the residents, and to gain their views of the service, assess key standards, and to follow up and assess as to whether previous requirements and recommendations had been met. The inspection included a tour of the premises, inspection of resident’s care plans, staff personnel records, medication storage and administration, meals and mealtimes, and inspection of a variety of other records. The inspector spent a significant part of the inspection talking with all the residents, and observing interaction between residents and staff. 6 feedback/comment cards were received from residents, 6 from relatives/visitors and 3 from health and social care professionals. The registered manager was present during the inspection, and the proprietor was present during part of the second day of the inspection. Staff kindly provided all the information, and documentation requested by the inspector during the inspection. 22 National Minimum Standards were assessed during the inspection and requirements from the previous inspection were judged as having been met. What the service does well: What has improved since the last inspection? Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 6 The home has worked hard to ensure that requirements from the previous inspection were met. Some records have been developed and improved. Several staff have had the opportunity to complete an NVQ level 2 in care. 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. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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 Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2,3 (6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive a statement of terms and conditions/contract when they move into the care home. Arrangements are in place to ensure that residents have their needs assessed prior to moving into the care home. EVIDENCE: Records confirmed that residents had received a written statement of the terms and conditions of the home. Fees were recorded in this documentation. The care home has an admission procedure. The registered manager reported that she and the provider assess prospective residents. Records confirmed that an initial assessment of the resident’s needs is completed prior to their admission to the home. This includes personal care needs, sensory needs, medication usage, interests, dietary needs, social contacts, and mobility needs. A resident spoke of having received an assessment of her needs prior to moving into the care home. From this initial assessment the resident’s plan of Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 9 care is developed. The manager confirmed that prospective residents have the opportunity to visit the care home, and are encouraged to have a meal with the other residents. A resident spoke of visiting the care home prior to her admission, another resident spoke of being admitted to the home from hospital. Relatives who kindly spoke with the inspector confirmed that they had visited the care home prior to their relatives’/friends admission. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7,8,9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s health social and personal care needs are set out in an individual care plan. There needs to be review, and development of some of the medication administration and training procedures to ensure that residents have their medication administered safely. Arrangements are in place to ensure that the residents are respected and their right to privacy upheld. EVIDENCE: Four residents care plans were inspected. These recorded resident’s health, social, and personal care needs, and staff guidance, to ensure that these needs are met. There was evidence that these care plans are reviewed at least monthly and updated to record any changes in needs. Resident’s weight is monitored. Records confirmed that resident’s health needs are met. Appointments with the GP, optician, dentist, chiropodist, were documented. A relative was taking Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 11 his relative (resident) to hospital for an appointment on the day of the inspection. Residents have access to mobility aids, which include wheelchairs and walking frames. There is a portable ramp (located away from the front door) for use at the front entrance for wheelchair users. A relative/visitor was unaware of this aid. The registered person should ensure that visitors are aware of how to access this equipment. Residents were positive about the staff, and confirmed that their privacy was respected. Staff were observed to respect resident’s privacy during the inspection. 6 feedback/comment cards received by the Commission for Social Care Inspection indicated that the residents felt well cared for. The registered manager reported that there were no residents with pressure sores. The medication administration and storage systems were inspected. Medication is stored securely. The pharmacist who supplies the care home with the resident’s medication was present during part of the inspection dispensing the resident’s prescribed medication into dossette boxes. Medication was observed to be administered unsafely during the inspection, and that infection control procedures were not observed during the administration of eye drops to residents. This was discussed with the registered manager, and the pharmacist during the inspection, and this method of administration of medication ceased during the inspection. The registered manager spoke of all staff having received a medication instruction during their induction. A staff member attended medication training during the week of the inspection. The registered person needs to ensure that all staff have recorded evidence that they have been assessed/judged as competent to administer medication. The registered person needs to supply the Commission for Social Care Inspection evidence of staff competency in the administration of medication. There needs to be evidence that all staff are aware of safe procedures for the administration of eye drops. The inspector was informed that a resident receives medication crushed. There needs to be recorded evidence that the pharmacist, (and GP) has agreed that if there is no alternative (i.e. liquid medication), that it is safe to crush medication. The medication policy needs to be reviewed to ensure that staff know what action to take if a medication error takes place. The registered person needs to supply the Commission with the reviewed medication policy. The pharmacist reported that she would assist in the review of the medication policy and procedures. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There needs to be further development in the provision of activities to ensure that all residents have the opportunity to participate in their preferred activities. The visiting arrangements are flexible and meet the needs of visitors and residents. Residents are supported to make choices. Meals provided are varied and nutritious. EVIDENCE: Records confirmed that residents do participate in some activities. These include watching television, reading the newspaper, listening to the radio, listening to music, catching ball, manicures. Two feedback comment cards from residents recorded that there was not enough activities provided, and two recorded that there were sometimes activities provided. Feedback from residents during the inspection informed the inspector that several residents thought that there were not enough activities, such as walks outside the care home in the community. Recorded feedback from three visitors recorded that they considered that there was insufficient activities (both mental and physical) for residents, one recorded that the television was on all day. There are three televisions in the sitting room, two of which are located fairly high on Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 13 the wall, one of these was on throughout the inspection, and it was unclear who was watching it. This should be reviewed. Residents spoke of enjoying the garden in the warm weather, and spoke positively of activities that were provided in celebration of various festivals. The registered manager spoke of residents enjoying a boat trip, and a shopping trip. The provision of activities was discussed with the registered manager and registered person. There needs to be review and further development of opportunities for residents to participate in preferred activities. Residents spoke of bringing personal items with them to the care home (see Standard 22 re inventories). Resident’s spoke of the support that they received from relatives, and friends in regard to the management of issues such as their financial affairs, and in assisting them to access community facilities. A comprehensive inspection of the systems in place to ensure that the meals provided are nutritious and wholesome took place during the inspection. This partly due to the need to assess this key standard but also in response to an anonymous compliant received by the Commission for Social Care Inspection. The menu was inspected, and judged to be varied and nutritious, and the lunch provide during the inspection matched the menu record. The menu should be recorded in a more accessible format for those residents who cannot read or are visually impaired, or are unaware of where the meal is recorded. The use of pictures was discussed. The cook kindly spoke with the inspector. She was very knowledgeable of the specialist dietary needs of residents and was observed to see each resident on both mornings of the inspection and offer them choice in regard to the meals provided on the day. The cook was knowledgeable of resident’s preferences. It was discussed with the cook ways of ensuring that individual residents were able to have particular things that they liked to eat, particularly on special occasions like their birthdays. She confirmed that she did regularly ask residents what they like and dislike. This interaction should be recorded, and take place regularly, such as in a planned resident’s meeting. Meals during the inspection were unhurried and residents reported that they were pleasant. A record of food eaten by residents was recorded. A variety of frozen, dried and tinned foods and fresh foods were stored. The cook and the manager spoke of residents being given fresh fruit, and fruit salads regularly, and that residents, when they ask could have fruit at anytime. The registered person should review/assess the issue of no longer having fruit accessible in the communal areas, particularly in regard to those residents who may not have the verbal skills to ask for fruit. Frozen products supplied to the care home, such as meat, needs to have the required ‘use by’ dates. The cook needs to obtain certified training in regard to food and hygiene. She spoke of planned training courses having being cancelled. All staff that participate in the preparation of food need evidence of having completed appropriate training. The cook confirmed that she did not assist residents with personal care tasks when she completes her cooking shifts. (See Standard 27 in regard to the issue of staff in the evenings cooking) Residents who kindly spoke with the inspector were positive about the meals provided. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 14 Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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): Standard 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to enable residents, relatives and others to complain. There needs to be further development, to ensure that there is at all times, appropriate action taken in responding to concerns and complaints. Arrangements are in place to ensure that residents are protected from abuse. EVIDENCE: Prior to this inspection an anonymous complaint was received by the Commission for Social Care Inspection. The issues recorded in the complaint were in regard to provision of meals, staffing, medication and some environmental issues. These issues were assessed as part of the inspection process, and requirements from this inspection are recorded in this report. The care home has a complaints policy and procedure. This is displayed in the home. There were no recorded complaints. Residents spoke of speaking to the manager or their family if they had a complaint. Two feedback comment cards received by the Commission informed the inspector that two residents, and two visitors were not aware of the complaints procedure, one resident recorded that they were sometimes aware of who they could speak to if they had a complaint. The registered person needs to ensure that all residents and visitors have knowledge and understanding of the complaints procedure. There had been a complaint in 2005 of items going missing from a resident’s room. The care home now completes an inventory of resident’s items. This inventory should be further developed to include all personal items that a Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 16 resident brings into the care home including clothing, and this inventory should be kept updated. The registered person spoke of the response taken by him in regards to this complaint. He needs to supply the Commission for Social Care Inspection recorded documentation that the complainant is satisfied with the action taken in response to the complaint. The care home has a protection of vulnerable adults procedure, and the Local Authority procedure. The manager reported that residents receive abuse awareness induction training. Staff who kindly spoke with the inspector were aware of the reporting and recording procedures in regard to protection of vulnerable adults. It is recommended that staff receive further protection of vulnerable adults training, and that advice in regard to this is sought from the Local Authority Adult Protection Co-ordinater. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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): Standard 19and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is very clean and generally well maintained. EVIDENCE: The inspection included a tour of the care home. The home is generally well maintained, but the flooring inside the passenger lift and the laundry needs repair. Residents spoke of liking their bedrooms. The home was warm and odour free. The garden is enclosed and maintained. A shared room needs a lampshade on the main light facility. The home is clean. The care home employs a part time domestic staff member who was off sick at the time of the inspection so care staff were completing the cleaning duties. Toilets/bathroom facilities were judged to be clean, with appropriate hand washing facilities. There needs to be evidence that staff have received training in regards to infection control. Laundry facilities are located away from food storage and food preparation areas. Feedback received from visitors/relatives informed the inspector that items of clothes occasionally get mislaid, but generally reappear. The Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 18 registered manager was aware of this issue, and reported that resident’s clothes are marked with the resident’s name and that staff work hard to ensure that items of laundry are not lost. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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): Standards 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Review of staffing numbers during certain times of the day needs to be actioned by the registered person to ensure that resident’s needs are met at all times. Arrangements are in place to ensure that residents are supported and protected by the home’s recruitment policy and practices. There needs to be development in regards to the provision of staff training to ensure that staff are competent to carry out their roles, and responsibilities. EVIDENCE: Two weeks staff rota was inspected. There are generally two care staff and the manager on duty during the mornings plus the cook and domestic member of staff. In the afternoons there are generally two care staff on duty from two pm or sometimes 4pm, and two staff on duty at night. There was recorded feedback from two visitors that they considered that there were not enough staff on duty in the afternoons and evening. This was discussed with the registered provider and the manager. Staff on duty in the evenings also prepare an evening supper for residents generally sandwiches/light hot meal. The registered person needs to review the staffing levels at this time, and include in this staffing review, how staff meet the needs of the residents, the layout of the building, the provision of activities for residents including community based activities such as walks out, providing supper, meeting Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 20 personal care needs of residents, medication, and managing an emergency if it arose. A random inspection of records of five residents informed the inspector that there had been eight falls by residents during the afternoon within the last six months. The incidence of falls needs to be considered when completing this review. This review documentation needs to be supplied to the Commission for Social Care Inspection. The manager reported that there had been two staff that had left the care home employment within the last few months, but that three part time staff had been employed to replace them. The registered person confirmed that he ensures that staff have good understanding of English, and are given support with the language if necessary, to ensure that residents needs are met. Residents were positive about the staff. The registered managers duties, and supernumerary shifts need to be included in the staffing review. The two weeks staff rota inspected recorded only one shift when she was not carrying out care duties. Staff who spoke with the inspector had knowledge and understanding of residents needs. Staff personnel files inspected included required information and documentation, including Enhanced Criminal Record checks. The registered person informed the inspector that two care staff were in the process of completing NVQ level 2 in care. There should be further development to ensure that all care staff have the opportunity to complete NVQ level 2 in care. Records confirmed that staff receive some staff training, and an induction programme. Staff reported that they received a comprehensive induction, which included shadowing other staff until they had an understanding of the individual needs of the residents. Staff spoke of receiving manual handling training and some fire training. Other training via video included dementia care training, and three staff, had completed emergency first aid in July 05. Training for staff was discussed with the registered person, and should be further developed to ensure that staff each has an individual training and development programme, and receive a minimum of three paid days training per year needs to be reviewed. The content of staff training needs to be recorded. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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): Standard 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is experienced in running the care home, and is aware of the need to complete the management and care qualification. She needs (with the provider) to review her shift duties, so that she is able to have more time to complete all the managerial duties in managing a care home. Systems are in place to ensure that the quality of the service is monitored, but they need to be further developed. Arrangements are in place to ensure that resident’s monies are well managed, and secure procedures are in place. The health and safety and welfare of residents and staff are protected. EVIDENCE: Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 22 The registered manager has managed the care home for several years. She is competent and particularly caring and sensitive in understanding and meeting resident’s needs. She is aware of the need to complete NVQ level 4 qualifications in management and care. The registered managers duties and supernumerary shifts need to be included in the staffing review (see Standard 27). The two weeks staff rota inspected recorded only one shift when she was not carrying out care duties. There needs to be evidence that she has adequate hours for completing the numerous management duties, to ensure that the home is managed appropriately, and that National Minimum Standards are continued to be met. The registered person (who completes the staff rota) needs to supply the Commission for Social Care Inspection with an action plan/review of the registered managers duties, and how these are met. Records confirmed that there were some systems in place to monitor the quality of the service. The registered person reported that he was in the process of completing an annual development plan for the service. The plan for 2004 was available for inspection and needs to be further developed to ensure that resident’s views and other interested parties are included in this process, so that aims and outcomes for them are met. There was some recorded evidence that required visits to the care home by the provider take place. The provider spoke of regularly visiting the care home. The need for continued recording of monthly visits was discussed with the registered person. He confirmed that he would supply this documentation regularly to the Commission for Social Care Inspection. No staff act as appointees for residents. Small amounts of monies are held for residents, and appropriate records and monitoring of monies held take place. There was evidence that required electrical checks and equipment checks are carried out. Household cleaning products are kept securely. There were no obvious health and safety issues apparent during the inspection. Required fire checks of are carried out, but there was only one recorded fire drill in 2005. Staff (including night staff) need to participate in a fire drill at least twice a year. Accidents, and incidents are recorded, but the action taken to minimise the risk of a resident falling again is not always recorded. This should be recorded. The registered person should regularly review incidents, of falls of residents in the care home. There needs to be recorded evidence that the temperature of resident’s bath water is monitored. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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 OP9 Regulation 12,13(2) (4) • Requirement The registered person needs to ensure that all staff have recorded evidence that they have been assessed/judged as competent to administer medication. The registered person needs to supply the Commission for Social Care Inspection evidence of staff competency in the administration of medication. There needs to be evidence that all staff are aware of safe procedures for the administration of eye drops. There needs to be recorded evidence that the pharmacist, (and GP) has agreed that if there is no alternative (i.e. liquid medication), it is safe to crush medication. The medication policy needs to be reviewed to ensure that staff know what action to take if a Timescale for action 01/08/06 • • • • Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 25 2 OP12 16(m) 3 OP15 12,13(4) 4 OP15 16(j) 18 5 OP16 22 6 OP19 23(2) 7 8 OP26 OP27 13(4), 16 (j) 18 12,13,18 (1) medication error takes place. • The registered person needs to supply the Commission with the reviewed medication policy. There needs to be further development of the provision of activities for residents and this provision be based upon feedback from residents. Frozen products supplied to the care home, such as meat, needs to have the required ‘use by’ dates. The cook needs to obtain certified training in regard to food and hygiene. All staff that participate in the preparation of food need evidence of having completed appropriate training. • The registered person needs to supply the Commission for Social Care Inspection recorded documentation that the complainant is satisfied with the action taken in response to the complaint. • The registered person needs to ensure that all residents and visitors have knowledge and understanding of the complaints procedure. • The flooring inside the passenger lift and the laundry needs repair. • A shared room needs a lampshade on the main light facility. There needs to be evidence that staff have received training in regards to infection control. • The registered person needs to review the DS0000017549.V287528.R01.S.doc 01/08/06 01/07/06 01/08/06 01/07/06 01/07/06 01/08/06 01/08/06 Page 26 Manor Lodge Version 5.1 9 10 OP30 OP31 18 10,18 11 OP33 24 (3) 12 OP38 18 13 OP38 12,13(4) staffing levels provided to meet the resident’s needs in during the pm/evening shift. • The incidence of falls needs to be considered when completing this review. The content of staff training needs to be recorded. The registered person needs to supply the Commission for Social Care Inspection with an action plan/review of the registered managers duties, and how these are met. The annual development plan for the care home needs to be further developed to ensure that residents views and other interested parties are included in this process, so that aims and outcomes for them are met There needs to be recorded evidence that staff (including night staff) participate in a fire drill/training at least twice a year There needs to be recorded evidence that the temperature of bath water is monitored, when residents have a bath. 01/08/06 01/08/06 01/08/06 01/07/06 01/07/06 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 OP8 OP15 Good Practice Recommendations The registered person should ensure that visitors are aware of how to access the ramp aid for use at the front door. • The registered person should review/assess the issue of no longer having fruit accessible in the DS0000017549.V287528.R01.S.doc Version 5.1 Page 27 Manor Lodge 3 4 OP18 OP28 communal areas, particularly in regard to those residents who may not have the verbal skills to ask for fruit. • Residents feedback in regard to their food preferences should be recorded, and this feedback should be enabled to take place regularly, such as in a planned resident’s meeting. • The menu/food provided on the day should be recorded in a more accessible format for those residents who cannot read or are visually impaired. It is recommended that staff receive further protection of vulnerable adults training. There should be further development to ensure that all care staff have the opportunity to complete NVQ level 2 in care. Manor Lodge DS0000017549.V287528.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Lodge DS0000017549.V287528.R01.S.doc Version 5.1 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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