Inspection on 19/10/05 for Manor Park

This inspection was carried out on 19th October 2005.

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 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 Park 04/09/08

Manor Park 31/07/07

Manor Park 27/04/06

Manor Park 26/04/05

Manor Park 25/11/04

Manor Park 16/07/04

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 Park 55 Manor Park Lewisham London SE13 5RA Lead Inspector Ornella Cavuoto Unannounced Inspection 19th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 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 Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor Park Address 55 Manor Park Lewisham London SE13 5RA 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 8522407 M & A Care Limited Mrs Sheila Ruby R Naik Care Home 13 Category(ies) of Dementia (4), Mental disorder, excluding registration, with number learning disability or dementia (1), Old age, not of places falling within any other category (13), Physical disability (1) Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 13 persons of whom up to 13 may be elderly, up to 4 may have dementia, up to 3 may be elderly with a physical disability, This home is registered for 13 persons of whom up to 13 may be elderly, up to 4 may have dementia, up to 3 may be elderly with a physical disability, up to 1 may have mental health problems and be over 55 years, up to 1 may have a physical disability and be over 55 years 26th April 2005 Date of last inspection Brief Description of the Service: Manor Park is a residential care home providing personal care and accommodation for thirteen people. It is owned by M&A Care Limited. The responsible individual has two other partners in the company. The home is located near to public transport facilities at Hither Green and is less than ten minutes walk along a level road to a parade of shops. The home was opened in 1996 and consists of a large detached property set back from the road. There are three storeys and a basement used for staff facilities and some services for the home such as the laundry. There are nine single rooms and two sharing. None of the rooms have en-suite facilities. There is a stair lift to the first floor and another small flight of stairs to the second floor where two more bedrooms are located. There is an extensive garden to the rear of the building. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced visit carried out over one day. The inspection involved speaking to three service users, the husband of one of the service users and staff on duty. Other inspection methods included speaking to the registered manager who was present for the duration of the inspection, a tour of the premises and examination of records. What the service does well: What has improved since the last inspection? Both the statement of purpose and the statement of terms and conditions have been revised to include all required information. The home has made some improvements around working with service users to identify their personal preferences and interests in order to assist in the development of individualised activities. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 6 The key worker system introduced by the home is being developed to ensure that service users receive a more individual and personalised service from staff. More information is being gathered around service users’ food likes and dislikes to ensure their personal tastes are catered for which has led to more variety within the menu. There have been some improvements in quality assurance with consultation with service users, family/friends and other stakeholders involved in the service. What they could do better: The service user guide needs to be revised to include more detailed information about the home as required by regulation. For those individuals referred through care management arrangements, a copy of the care management assessment must be obtained and used as the basis for drawing up the service user plan. Service user plans and risk assessments need to be signed by service users, family/friends or a representative where appropriate to demonstrate that service users or other relevant persons have been involved in the care planning process. Regular reviews need to take place and recording within service user plans needs to be carried out consistently. Risk assessments for service users need to be more comprehensive detailing action to be taken to minimise the risks identified and the social care needs of individuals need to be addressed more effectively as part of the care planning process. Improvements made around the keyworker system and ensuring individualised activities are carried out with service users need to be consolidated and undertaken on a regular basis. The home’s policy and procedure on the protection of vulnerable adults needs to be reviewed and updated. Although planning permission has been obtained and drawings are in place, work has yet to start to improve access to front of the building by installing a ramp. Furthermore, access inside of the home to the first and second floors for service users requires consideration. There are gaps in staff’s training, specifically mental health awareness, that needs to be addressed to ensure the staff team can meet all aspects of health, welfare and safety of service users. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 7 Quality assurance systems need to be expanded and consolidated to ensure self-monitoring is more comprehensively addressed and to ensure the home is run in the best interests of service users. The home’s recruitment practice needs to be improved to ensure the protection and safety of service users. Systems used in respect to the receipt and monitoring of service users monies need to be improved to ensure that service users financial interests are safeguarded. Staff are not currently in receipt of regular supervision nor have they had an annual appraisal. 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 Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3&4 Standard 6 is not applicable. The service user guide does not contain all the required information to enable service users to decide if the home can meet their needs. Not all service users had a copy of the care management assessment on file. A lack of specific training may detract from the ability of the staff to ensure that appropriate care is provided. EVIDENCE: Subject to a previous requirement, the statement of purpose has been revised to ensure that it includes all the required information. However, the service user guide still needs to be changed to ensure it contains a description of individual accommodation and communal space, relevant qualifications and experience of the staff team and any special needs or interests catered for by the home. It should also be altered to include the name of the Commission for Social Care Inspection and the revised copy should be dated to ensure service users receive the updated version. Therefore, this requirement has only been partially met and will be re-stated in this report. It was evident that all service users had had an assessment carried out by the home. However, only the more recently admitted service users had a copy of Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 10 the care management assessment on file. For all service users referred through care management arrangements a copy of the care management assessment needs to be obtained and kept on file. Subject to a requirement. One of the registration categories of the home includes mental disorder. Subject to a previous requirement, the home was instructed not to admit any service users with mental health needs until staff receive specific training in this area to assist them to support service users admitted to the home with a mental disorder. It was reported that there have not been any admissions in respect of this category of registration and training for staff is still to be arranged. Therefore, this requirement remains unmet and is restated in this report. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 The care management assessment is not providing the basis for the care plan drawn up by the home. Health care needs are comprehensively met but in terms of personal care there were inconsistencies with recording within service user plans. The social care needs and risk factors in relation to service users are not fully addressed. Care plans are not being regularly reviewed and there is insufficient evidence that service users are involved in the care planning process. EVIDENCE: Three service user plans were inspected. All contained a comprehensive assessment of need carried out by the home. However, as previously stated only those service users who had been more recently admitted to the home had a copy of the care management assessment on file. In addition, it was evident from one service user’s file that was examined that the care management assessment had not been used as the basis for drawing up the care plan by the home as needs and risk factors identified within the assessment had not been addressed. Subject to a requirement. In relation to health care needs these were comprehensively met with evidence of good liaison with a variety of healthcare professionals such as district Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 12 nurses, occupational therapists, opticians, dentists and chiropodists. However, in terms of personal care there were inconsistencies in recording. One service user plan where there were particular concerns about the service user addressing their personal hygiene, personal care received and efforts by staff to encourage the service user to bathe/shower had been carefully recorded. Yet, in respect to the other plans inspected there were gaps in recording indicating that personal care needs were not being adequately met. Subject to a requirement. Social care needs were not comprehensively addressed within service user plans and although there was evidence to indicate that two care plans had been reviewed regularly, one care plan and all the risk assessments inspected had not been reviewed at all. Furthermore, there was no indication that service users, family/friends or a representative where appropriate have had any input in the care planning or reviewing process. Subject to a requirement Also, although risks were identified there was not always adequate information about control measures to minimise the level of risk and ensure it is managed effectively. Moreover, needs identified within the care plan such as noncompliance with medication was not followed up within the risk assessment. This shortfall has the potential to adversely affect the welfare of service users. Previously subject to a recommendation, this is re-stated as a requirement in this report. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 &15. Improvements have been made to ensure staff spend time with service users in individualised activities as well as group activities to match their expectations and preferences but records kept indicate these are not undertaken regularly. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome, appealing and balanced diet. EVIDENCE: The home has made improvements in trying to engage service users in individualised activities by utilising the key worker system, which is being developed on an ongoing basis. A policy outlining the responsibilities of the key worker has been drawn up to assist staff with fulfilling the role. An Activity File is now in place within which there was some evidence of personal life histories that had been drawn up with service users by their key workers. In addition, each service user had an individual activity programme that stated their dislikes, interests/preferences, time spent with the service user and the activity that was undertaken. However, recording indicated that this was not occurring on a regular basis which, limits effectiveness. The home does also offer a weekly programme of activities which includes sing alongs, board games, quizzes, bingo, arts and crafts, taking residents out for walks or going to the local shops and activities linked to reminiscence. However, service Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 14 users spoken to stated they had never played bingo and one service user said, “It’s a bit boring sometimes”. There was no evidence to indicate individual or group activities are being evaluated with service users to assess the appropriateness of the activities, the extent to which they have been enjoyed, that preferences and interests are being met and who has participated. This is particularly important for those service users suffering from dementia. Subject to previous recommendations and a requirement these have been partially met but a requirement is to be restated in this report. It was also noted from training records that none of the staff had recently attended a course in reminiscence. This could assist staff in the organisation of activities for those service users with dementia and is subject to a recommendation in this report. In relation to religious observance, there are visits from the local clergy and one service user spoken to was assisted in attending the church of her choice. It was also evident from speaking to service users that they are able to exercise choice and personal autonomy. One service user said “I can get up and go to bed when I want to”. Another service user made a similar statement. In respect to meals, the menu was examined which clearly indicated that a choice is offered to service users, who expressed satisfaction about the food provided. One service user stated “The food is alright here, you can get more if you want it”. Subject to a previous recommendation, there was some evidence of food likes and dislikes recorded in service user files. In addition, improvements to the menu have been made offering a wider choice of desserts to ensure service users particular preferences are met. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 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): 18 Service users are protected from abuse. However, the home’s adult protection policy is in need of reviewing and updating. EVIDENCE: There was evidence to indicate that staff have undertaken adult protection training and staff spoken to have good awareness in relation to the protection of vulnerable adults. However, the home’s adult protection policy and procedures are in need of being reviewed and updated to include more information about the different forms of abuse, indicators that an individual might be experiencing abuse, information in relation to the Protection of Vulnerable Adults (POVA) register and references to relevant legislation. Subject to a requirement. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21 &22 The home provides a safe and homely environment for service users, although there are issues regarding access for individuals with deteriorating mobility. In general, service users have access to safe and comfortable outdoor and indoor communal facilities. There are sufficient lavatories and washing facilities but these all need to be kept in good working order. Access to the front of the building is inadequate for service users. EVIDENCE: In general, the home provides a safe, homely and well-maintained environment. However, the accommodation is on three floors and this presents access issues inside the building. For, although there is a chair lift to the first floor, all service users except for those who have rooms on the ground floor have to be able to climb stairs. This issue has clearly impacted on the home in terms of under occupancy. It was reported that there have been problems in placing individuals in the home due to the inaccessibility in particular, to the second floor, where two bedrooms are situated. Consideration also needs to be given to those service users presently in residence whose bedrooms are on the Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 17 first floor in terms of how the home will address this problem as mobility and health needs increase. Previous requirements have been stated in relation to this issue. An OT assessment was carried out in July 2004 and in September 2004 CSCI received proposals to extend and adapt the home in a way that would address access difficulties but it appears these plans were later considered not to be feasible. However, due to ongoing concerns, a requirement is re-stated in this report. Communal facilities outside and inside the home are generally safe and comfortable. There is access to a large well-maintained garden at the rear with a sheltered area for service users to sit. The lounge and dining room are a good size and well furnished. However, there were concerns about hoist equipment being kept in the lounge whilst being charged presenting a health and safety risk to service users. Alternative storage should be looked at or consideration given to charge the hoist overnight when all service users have retired. Furthermore, in respect to staff sleeping in facilities, these are unsuitable with a sofa bed placed in the office that is very cramped and makeshift. It was reported that staff are actually using one of the service user’s bedrooms that is presently empty as a sleep in room due to the impracticality of the arrangements in place. More appropriate sleeping in facilities for staff need to be put in place. Subject to requirements. Although there are sufficient toilets and bathrooms, subject to a previous recommendation the toilet on the first floor is still awaiting work to be carried out on the toilet flush to make it easier for service users to use. This is to be restated as a requirement in this report. Also, in relation to access a previous requirement has been the need for the installation of a ramp at the front of the building. Despite planning permission being in place, building work has not yet commenced. Therefore, this is restated as a requirement in this report. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 18 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): 29 & 30 Service users have not been adequately protected by the home’s recruitment policy and practice. Staff are trained and competent to do their jobs. Yet, specific training is required to ensure the team can meet the presenting needs of all the service users. The registered manager must ensure that staff receive an annual appraisal to plan future training needs. EVIDENCE: Four staff files were inspected. Not all contained the necessary documents required by regulation. Of particular concern was a recently appointed member of staff who had been working within the home without the appropriate police checks in place or the Protection of Vulnerable Adults register being checked. An immediate requirement to address this matter was issued and evidence was sent to CSCI immediately following the inspection that the Criminal Bureau form and request for a POVA First check had been sent. However, two staff records were also found to have only one reference on file. It is essential that all recruitment records are in place prior to staff being confirmed in post and begin working and practice in recruitment is safe. Subject to a requirement. All staff are trained and competent to do their jobs. An induction booklet has been introduced by the registered manager and has been used to induct the new staff member and was seen to be comprehensive. There was also evidence of a training and development plan for each staff member having an individual training record. All staff have completed the statutory training, which is regularly updated, and all have achieved the NVQ Level 2 in care. In terms Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 19 of additional training for the staff team, it was reported that they have all recently completed a course in Understanding Difficult Behaviour as part of dementia awareness and have also undertaken adult protection training. Staff spoken to confirmed this. However, the previous requirement of staff receiving training in mental health awareness has not been met. There was no evidence of annual appraisals having been undertaken with staff. This is important to ensure staff development is addressed and to identify future training needs. Subject to a previous requirement, this is re-stated in this report. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35&36. The home is generally well run and managed by a person who is fit to be in charge and is of good character. However, the registered manager lacks the necessary support in relation to managing workload and information technology equipment to be able to discharge her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. Some improvements have been made in relation to quality assurance but systems in place to self-monitor performance remain limited. Service users’ financial interests are not being safeguarded completely. Staff are not being regularly supervised. EVIDENCE: The registered manager has been in post for just over a year. She is currently undertaking the Registered Manager Award and NVQ Level 4 in care and management and is also doing a Supervisory Management course that she is due to complete shortly indicating that she is taking responsibility for updating Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 21 her knowledge and skills. However, there was evidence to indicate that the manager was experiencing problems with workload management and requires additional support specifically in relation to administration to be able to discharge her responsibilities fully. Access to a computer would also facilitate the completion of these tasks. Subject to a recommendation. Discussions and observations of interactions between staff, service users and the manager gave a strong indication that there is a positive and inclusive ethos within the home and that the manager is approachable, supportive and very committed. Feedback from staff confirmed that the manager does welcome and listens to ideas and contributions from staff. In relation to quality assurance systems, there was evidence that the manager had drawn up a questionnaire to obtain feedback from service users, family members and other stakeholders involved in the home, the results of which have been compiled and was recently reported back. Overall, feedback received was positive. In respect to other systems to enable the home to monitor its performance, these were limited. Resident meetings are held. Minutes were inspected that indicated these are well attended by service users but they have not been held regularly. The home did not have an annual development plan in place or evidence of an internal audit. Policies and procedures observed are in need of review and to be updated. Also, the manager could not provide evidence of monthly provider visits. Subject to a previous requirement this has been partially met and therefore is restated in this report. Random samples of four records of resident’s finances that are managed by the home were examined. Each service user has their own individual petty cash account that details transactions and receipts are being kept. All records inspected reconciled with the balance of monies held by the home. Yet, only one account showed evidence of being regularly signed by the manager/staff member and the service user when transactions had been carried out. The manager carries out a self-audit of service users finances every fortnight but stated that external audits are not carried out. No valuables other than money and saving account books of those that are under appointee ship with the registered provider were held on behalf of residents and these are kept secure in the home’s safe. However, it was noted that the home did not have a form detailing valuables /possessions handed over for safe keeping which is signed by the service user and staff and kept as a record. This needs to be put in place. Subject to requirements. A recommendation is also to be made that a more secure alternative to the paper envelopes being presently used for storing service users’ individual money be looked into. Staff files sampled did not include evidence that staff are receiving regular individual supervision. Staff spoken to gave mixed responses when asked about supervision. Records of supervision seen indicate appropriate discussion and topics are covered but that for some staff members there has been a Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 22 considerable gap since their last supervision session. Subject to a previous requirement this is to be restated in this report. Staff meetings are held regularly. Copies of minutes were seen that covered a range of topics including training, practice issues in relation to service users and general matters to do with day to day running of the home. Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 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 2 2 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 2 2 1 X X X X STAFFING Standard No Score 27 X 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 2 1 X X Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 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(a)&(c) Requirement The registered person must ensure that the Service User Guide contains a full description of individual accommodation and communal space, staff qualifications and any special needs or interests catered for by the home, the name of the Commission is included and all service users receive an updated copy. (Previous requirement of 26/04/05 partially met.) The registered person must ensure that a copy of the care management assessment is obtained for all service users referred through care management arrangements and this is kept on file. The registered person must ensure that appropriate training is made available to staff to ensure the specific needs of service users with mental health problems can be met effectively. The registered person must ensure that the care management assessment DS0000025632.V258271.R01.S.doc Timescale for action 30/04/06 2 OP3 14(1)(b) 30/04/06 3 OP4 18(1)(a) (c)(i) 30/04/06 4 OP7 15(1)of 30/04/06 Manor Park Version 5.0 Page 25 5 OP7 15(1)&(2) 6 OP7 13(4)(c) provides the basis for the care to be delivered to service users. The registered person must 30/04/06 ensure that the service user plan sets out in detail the action which needs to be taken by staff to ensure that all aspects of personal and social care of service users are met, specifically that recording in respect to personal care within service files is consistent and the plan is drawn up and regularly reviewed with the involvement of the service user and signed by the service user, family member and/or representative where appropriate. The registered person must 30/04/06 ensure that risk assessments fully set out details of control measures and action to be taken in respect to minimising the level of those risks identified within service user plans. The registered person must ensure that service users are consulted and feedback obtained on individual and group activities to ensure that they are being an opportunity to participate in recreational and leisure activities that match their personal preferences and expectations. Further, that individual and group activities are undertaken on a regular basis. (Previous requirement of 26/04/05 partially met.) The registered person must ensure that the home’s adult protection policy is updated with reference to relevant legislation. The registered provider must make available to the Commission an action plan indicating how he intends to DS0000025632.V258271.R01.S.doc 7 OP12 16(2) (m)&(n) 30/04/06 8 OP18 13(1)(6) 30/04/06 9 OP19 23(1)(a)& (2)(a) 30/04/06 Manor Park Version 5.0 Page 26 10 OP20 13(4)(a) &23(l)(3) (b) 11 OP21 23(2)(c) 12 OP22 23(2 (a)& (n) 13 OP29 19&Sch 2 14 OP30 18(1)(c) (i)&(2) 15 OP33 24&26 16 OP35 16(l)&17 improve accessibility to the first and second floors for service users as their mobility and health care needs increase. (Previous requirement of 26/04/06 not met.) The registered person must a) ensure that a more suitable storage place is identified for the hoist to be charged or it is charged overnight when service users have retired to eliminate any risks to the health and safety of service users. b) arrange for more suitable sleeping in facilities for staff. The registered person must ensure that the repairs to the toilet on the first floor are carried out. The registered person must ensure the installation of a ramp to the front of the building is carried out. (Previous requirement of 26/04/05 not met) The registered person must ensure that staff do not begin working in the home until all documents required by regulation are in place. The registered person must ensure that all staff receive an annual appraisal to facilitate the identification of future training needs. The registered person must ensure that a comprehensive and effective quality assurance system is put in place to monitor and review all aspects of practice within the home. Also, as part of quality assurance that monthly provider reports are carried out and sent to CSCI. (Previous requirement of 26/04/05 partially met.) The registered person must DS0000025632.V258271.R01.S.doc 30/04/06 31/01/06 28/02/06 20/10/05 30/04/06 30/04/06 30/04/06 Page 27 Manor Park Version 5.0 (2)&Sch 4 (9) 17 OP36 18(2) ensure that all service users financial records are accurately maintained specifically that all transactions are signed for by the service user and a staff member and that a form is developed to record the deposit of all valuables /money that have been handed over for safekeeping to the home. The registered person must 30/04/06 ensure that all staff receive individual supervision at least six times a year and that this is recorded and the notes taken are kept on file. (Previous requirement of 26/04/05 not met). 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 OP12 OP31 Good Practice Recommendations The registered person should consider arranging for staff to attend a course in reminiscence to assist in the development of activities for service users. The registered provider should consider providing the registered manager with more resources in terms of providing administrative support and/or a computer to enable her to discharge her responsibilities fully. The registered manager should consider alternative ways of individually keeping service users’ money such as the use of transparent cases, which can be zipped to ensure monies are kept secure. . 3 OP35 Manor Park DS0000025632.V258271.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Park DS0000025632.V258271.R01.S.doc Version 5.0 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. 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