Inspection on 26/04/05 for Manor Park

This inspection was carried out on 26th April 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 19/10/05

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 Ruth Mathiesen Unannounced 26th April 2005 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 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 G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Manor Park Address 55 Manor Park, Lewisham, London, SE13 5RA Telephone number Fax number Email 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 852 2407 M & A Care Limited CRH Care Home 13 Category(ies) of DE Dementia registration, with number MD Mental Disorder of places OP Old Age PD Physical Disability Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 Date of last inspection 25th November 2004 Brief Description of the Service: Manor Park is a care home providing personal care and accomodation for thirteen people.It is owned by M&A Care Limited. The responsible person 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. There are nine single bedrooms and two sharing rooms. None of the rooms have en-suite facilities. There is a stair lift up one flight of stairs but there is another small flight of stairs to provide access to the first floor and another flight to the two rooms on the top floor. There is an extensive garden to the rear of the building. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over eight hours. The inspector spoke to several service users, three members of staff and the manager. Six people were resident at the home on the day of the inspection. The inspector looked around the house and checked records. What the service does well: What has improved since the last inspection? There has been some improvement to the recording of information within the service user plans particularly in relation to the use of monitoring charts and risk assessments to ensure the protection of service users from falls. More social activities have been offered to service users and records are kept to assist with knowing what activities work and what don’t. A training programme has been devised and there are plans to offer staff intermediate dementia training and protection of vulnerable adults training. Areas of the home have been redecorated and the carpet in the lounge has been replaced. Ramps have been placed at the rear of the building enabling Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 6 residents to use the garden. The home has bought a new dishwasher and a tumble dryer. What they could do better: The statement of purpose, service user guide and term and conditions do not contain all the information required by standard. Although service user plans contain good information about health and personal care there is a lack of information in relation to person’s life history, preferred routines and what is important to them, which may mean individual needs are being overlooked. The plans of service users who experience difficulties with expression or understanding do not contain adequate information about how the person communicates and how others should communicate with them. Individual activity plans need to be developed that cater for the needs of each service user, including people with dementia and those people who spend a lot of time in their bedrooms. People who need or want to maintain and develop skills must also be catered for. Activity records kept by the home are not sufficiently detailed to enable effective monitoring. The keyworker role is underdeveloped and service users are not gaining maximum benefit from them. Service user plan reviews are taking place but with the limited participation of service users and people important to them. Service user and relative meetings are not sufficiently frequent. There is a lack of information about food likes and dislikes of service users and the dessert choices appear limited. Work has yet to start on improving access inside the home and at the front of the building. The overall appearance of the lounge should be made more attractive. An effective and comprehensive quality assurance system needs to be developed to ensure the service is reviewed and service users are confident that their views are taken into account. Staff are not receiving supervision on a regular basis and staff performance appraisals have not taken place in the last two years. Training to help staff support people with mental health needs has not yet taken place. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4 Service users do not have access to a satisfactory statement of purpose and service user guide to enable them to decide if the home can meet their needs. A procedure is in place to ensure service users’ needs are assessed prior to a decision being made about their admission to the home. A lack of specific training may detract from the ability of staff to ensure that appropriate care is provided. EVIDENCE: A statement of purpose and service user guide has been devised. However the documents lack certain aspects of required information and the way they are set out and worded makes them difficult to access. There is a copy of the service user guide (including a sample contract/ statement of terms and conditions and the complaints procedure) in each bedroom although not everyone has the most recently updated copy. The statement of terms of conditions does not contain full information about the fee and what is included in the fee and what isn’t. Concerns were expressed at previous inspections about the home admitting too many residents with mental health and dementia issues and exceeding the Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 10 registration category of the home. Last year the CSCI required that no further service users with mental health needs be admitted and that variations must be sought where appropriate and suitable training be provided to staff. There have been no admissions to the home since the last inspection. Staff have been provided with basic dementia care training and there are plans to provide intermediate training to better equip staff to care for service users with dementia. As yet there has been no specific training to assist staff to support service users with mental health issues. A procedure has been devised to ensure prospective residents are assessed prior to admission to the home. Current service users who were admitted via the local authority have had a community care assessment and a service user plan developed. These documents were seen on individual files. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10,11 Service users’ health and personal care needs are generally well met. Service user plans are generally effective although they contain insufficient information in relation to social needs and risk, which may mean that aspects of the service users wellbeing are overlooked. Service users plans are regularly reviewed, although people living at the home and those important to them are not sufficiently involved in the process. The systems for the administration of medication are good and ensure that the service users’ medication needs are met. EVIDENCE: Several service user plans were examined and were found to contain relevant information. Records are kept of the action that needs to be taken by staff to ensure that aspects of a person’s health and personal care needs are met. Where necessary the home liaises with health professionals such as the infection control team and the dietician. Notes are kept of visits from health professionals, visits from relatives and friends and significant events. Food and fluid monitoring is undertaken as necessary. Annual care management reviews have been undertaken for people living at the home. The home reviews service user plans every month, although service Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 12 users and their relatives are not sufficiently involved in the process and their views of the service are not recorded. Staff possess a great deal of knowledge about individual service user’s needs, and are able to give more information than is recorded in the plans. One service user’s long term assessment gave a very good feel of the person; however, plans generally do not contain enough information about what is important to the person, communication issues, personal preferences and end of life wishes and the shortfall has the potential to adversely affect the teams ability to fully address individual needs. The proposed registered manager explained that she had recently introduced manual handling checklists and that staff awareness has been raised in regard to managing risk. Since the last inspection some action has been taken to improve risk assessments and guidance to staff. However, risk assessments still do not contain adequate information about control measures, how staff should work in risk situations and how the service user can be supported to help them avoid risky situations. Entries in the accident book coincide with daily diary records. There were some instances where significant events took place such as the person being unwell and outcomes were not recorded within the individual plan. Medication arrangements are satisfactory and staff who administer medication have been provided with appropriate training. No controlled drugs are prescribed to service users and the returns book is signed by the pharmacy. None of the current service users self-medicate and none have expressed a wish to do so. People living at the home said they are treated with dignity and respect and their privacy is supported. This was observed on the day of the inspection although it was seen that a small number of service users need more support with their personal care. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 Some social activities are offered by the home although provision is not yet sufficiently developed to ensure individual needs and interests are satisfied. The home encourages contact with family and friends. Resident and relative meetings do not take place regularly enough to ensure people can effectively contribute to decision-making about all aspects of the service. Service users expressed satisfaction with the quality of food provided and with the serving of meals, snacks and drinks. Dessert choice may not be wide enough and records of individual food likes and dislikes are not sufficiently detailed to ensure needs can be identified and met. EVIDENCE: People living at the home said they are able to exercise choice in relation to their daily routines. During the day residents can spend time in their rooms, watch TV or sit, chat to other residents. Some social activities are organised by staff including word games, bingo, dominoes, sponge ball, sing alongs, board games and entertainers. There are occasional visits from the local clergy. However, activities appear to be limited in variety and frequency and there appears to be no structured or comprehensive approach to provision. One resident said, “I am bored with sitting here with the TV on all day and the other people can’t talk to you. I’m just so fed up. I would like to go out occasionally but I don’t get asked.” Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 14 The proposed registered manager explained that with only six residents staff have more time to spend with service users and they were actively being encouraged to do so. There are plans for trips to the park, shops and places of interest in the summer and the manager plans to contact Pump House museum to assist with activities for people with memory impairment. Some information about service users’ interests and hobbies is included in the service user plan although not enough to effectively support the provision of individualised activities, especially to those people with specific needs and memory difficulties. Some activities are recorded but not in sufficient detail to indicate what aspects people enjoyed and what they might like to do in the future. It is difficult to determine what is actually provided by staff and an activity such as listening to music does not appear to require their direct involvement. A keyworker system is in place although the role is not sufficiently developed particularly in relation to supporting individualised activities with service users. Service users are supported to keep in contact with their families. One visitor said, “ Staff are very friendly here and I see that they treat people very welllike members of their family.” Another visitor was complimentary about the home and thought that it was ideal for their relative and couldn’t imagine them living anywhere else. Resident and relative meetings take place from time to time although the frequency may not be enough to ensure people’s views are sufficiently heard. Minutes indicate a variety of topics are discussed. Service users’ rooms are nicely personalised. Wherever possible service users are encouraged to exercise personal autonomy and choice. One service user said, “I can get up at whatever time I like in the morning.” A part time cook produces lunch and tea. Service users expressed satisfaction with the quality and quantity of food provided by the home. Some service users confirmed that there is an alternative choice at mealtimes. The 4-week menu was examined and there appears to be a narrow range of desserts. Meals are provided for diabetics and other special diets can be catered for. There is not enough information about food likes and dislikes on service user files, which may mean people do not get the chance to eat things they particularly enjoy. Refreshments are provided throughout the day and snacks and drinks were seen in service users’ bedrooms. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 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 standard(s) 16,17,18 There are satisfactory systems in place for managing complaints and financial matters, which safeguard service users. The home supports service users in exercising their right to vote. Policies and procedures are in place to protect vulnerable service users from abuse. EVIDENCE: There is a complaints policy on display and a copy is also included in the statement of purpose. The complaints log was not examined on this occasion. Service users able to express an opinion felt that if they had a complaint it would be appropriately dealt with by the home. The inspection took place shortly before the general election and it was explained that service users have the opportunity of a postal vote and that support would be available for service users wishing to visit the polling station. Information about the different political parties was seen in the lounge. Evidence indicates that staff have a basic awareness in relation to the protection of vulnerable adults from abuse although they will shortly be provided with more formalised vulnerable adults training. Staff have also been given information about policies and procedures such as physical and/or verbal aggression by service users and whistle blowing. There has been a recent vulnerable adults issue referred to the local social services department for investigation. The home has acted appropriately in dealing with this situation. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 16 The home’s approach to service user finances ensures that service users interests are safeguarded and recruitment practices protect service users from abuse. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 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 standard(s) 19,20,24,26 The home provides service users with safe and homely surroundings although there are issues with access for people with deteriorating mobility. Good cleanliness and hygiene is maintained in the home ensuring the welfare and safety of service users. Specialist equipment is acquired as necessary to ensure service users needs are met. EVIDENCE: The accommodation is on three floors and this presents access issues inside the building as, although there is a chair lift to the first floor, all service users except those living on the group floor need to be able to climb some stairs. Access at the front of the building also presents a problem for people with mobility difficulties. Requirements have been made in relation to access issues at the last three inspections. In September 2004 the home provided the CSCI with correspondence relating to proposals to extend and adapt the home in a way that would address access difficulties. Since the last inspection ramps have been installed at the rear of the building making the garden accessible to service users. In July 2004 the CSCI were informed that an OT assessment had Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 18 taken place and a ramp would be provided at the front of the building as soon as possible. At the time of this inspection work had not yet commenced on the ramp at the front of the building and there were no firm plans in place to alter the inside of the building. Therefore the requirement remains in place. The home was clean and hygienic on the day of the inspection and there were no undesirable smells. The home is safe and it is evident that routine maintenance and some renewal of the fabric and decoration of the premises take place. Service users spoken to say they are happy with their surroundings. Shared areas and bedrooms are comfortable and homely although some items of furniture are showing signs of age and the main lounge would benefit from being made more attractive. Bedrooms have been personalised to suit the needs of service users. Bedroom doors can be locked with a key if the service users wish. Lockable storage facilities are available in the bedrooms. The laundry facilities meet current requirements and the washing machines are capable of dealing with the demands of the home. The tumble dryer has been recently replaced. Equipment is made available to enable staff to attend to the specific needs of service users where this is required. The chair lift is regularly serviced and there is an accessible call system in every room. One of the service users mentioned that the toilet flush in the upstairs bathroom was quite difficult to use and asked for it to be changed. At the last inspection staff sleeping in facilities were located in the residents lounge. Since then the sofa bed has been placed in the office although arrangements are cramped and makeshift. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Staffing levels ensure that service users are safe, and that the premises are clean and hygienic. Basic staff training is provided by the home although more specific training is required to ensure the team can meet all aspects of the health, welfare and safety of service users. There are effective staff recruitment procedures in place offering protection to people living at the home. EVIDENCE: The staff team are well established, appropriate to the home and possess between them a wealth of skills and knowledge in working with older people. The rota indicates that there are sufficient staff on duty at all times and there is a high level of retention in the staff team. A training and development plan has been developed for the team and there are individual staff training records. The proposed registered manager is in the process of improving the induction programme to ensure it meets Skills for Care standards. Staff have been provided with basic training and there are plans to provide relevant update training. All of the care staff have achieved an NVQ in care at level 2 and some intend to undertake an NVQ at Level 3 which is to be commended. At the last inspection a requirement was made that training be provided to enable staff to meet the needs of service users with mental health issues or dementia. The home plans to provide intermediate dementia training although the date has yet to be confirmed. There are no plans for offering mental health Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 20 training therefore the requirement remains in place until it can be assessed as met. The necessary staff recruitment information is obtained including CRB’s and references to ensure the protection of the service users. Service users spoken to said that staff are kind and caring and that they respond promptly to requests for assistance. Observations of interaction between staff and service users indicate that staff use appropriate approaches and skills. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36,37,38 The home is generally being managed effectively. A quality assurance system is not sufficiently developed to enable service users and other stakeholders views to influence the way the service is run. Staff are not receiving individual supervision and performance appraisal to the required frequency making it difficult to monitor whether individuals are working in a way that continues to meet the needs of people living at the home. Working practices and associated records generally ensure that the health and safety of service users is promoted. EVIDENCE: Service users, staff and visitors made positive comments about the home and the way it is run. One person commented that the manager’s leadership “is of great benefit to the home, she is approachable and listens”. The Commission has received her application for registration and she is currently undertaking the Registered Manager Award. There is evidence that she obtains advice and up to date information about her role as registered manager. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 22 The provider carries out monthly monitoring visits and notes of these visits were checked during the inspection. The requirement to notify the Commission of events affecting the well being of service users under Regulation 37 has now been met. Some feedback is gathered about the quality of the service through everyday contact and meetings. However the last quality assurance survey took place in December 2003 and there is no comprehensive system in place to regularly gather feedback from service users, relatives and other professionals and enable their views to continually influence service development. The proposed registered manager said that she plans to send out another survey soon. Permanent staff and bank staff spoken to on the day confirm that they are offered supervision, which they find useful. Notes were examined which indicate appropriate discussion and recording. However not all staff receive supervision on a regular basis. Records show that it has been some time since all staff have had their performance appraised. Staff meetings are held every couple of months and recent minutes were examined and found to reflect a variety of relevant issues. Written statements of policy and procedure have been devised for maintaining safe working practices. There has been some improvement in service user plan recording and service users information is held securely. Recording in the accident book is satisfactory and entries coincide with notes made in service user plans. The fire system is subject to regular tests and equipment is suitably checked. Maintenance records are held appropriately the relevant certificates are in place and up to date. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 2 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION 2 2 x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 2 x x 2 3 2 Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 4 (Sched 1) Requirement Timescale for action 31.10.05 2. OP1 5 3. OP2 5(1b,3) The Registered Person must ensure that the Statement of Purpose contains the relevant information in relation to Schedule 1 points 1,2,6,7,9,10,13,15, and 18. The Registered Provider must ensure 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 documents must be reorganised and in places reworded to improve accessibility. (Timecales of 30.04.03, 01.07.04 and 30.03.05 partially met) The Registered Person must 31.10.05 ensure that all service users are provided with a copy of the service user guide every time it is updated. The Registered Person must 31.10.05 ensure that the service users statement of terms and conditions/contract for their residency contain full information about the care covered by the Version 1.30 Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Page 25 4. OP4 18(1a,c1) 13.6 5. OP12 16(2m) 6. OP19 23(1a)23 (2a) 7. 8. OP30 OP33 18(2) 24 9. OP36 18(2) fee and additional services to be paid for over and above those included in the fee. (Timescale of 1.01.04, 30.08.04 and 31.08.04 not met) The Registered Provider must ensure that suitable training is made available to staff and systems are put in place to ensure the specific needs of service users with mental health issues and dementia are better met. (Timescale of 30.03.05 not met) The Registered Provider must, in conjunction with service users, keyworkers, family and appropriate others, develop and activity programme that includes both individual and group activities and caters for the needs of all service users. (Timescale of 31.04.05 partially met) The Registered Provider must make available to the Commission an action plan indicating how he intends to improve access to the front of the building and make all bedrooms accessible to service users.(Timescale of 31.03.03, 3.09.04 and 31.03.05 partially met) The Registered Provider must ensure that all staff receive annual performance appraisal. The Registered Provider must develop an effective and comprehensive quality assurance system for reviewing and improving the care provided within the home. The Registered Provider must ensure that all staff receive individual supervision at least six times a year.(Timescales of 01.03.04 and 30.03.05 partially 31.10.05 31.10.05 31.10.05 31.10.05 31.10.05 31.10.05 Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 26 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. Refer to Standard OP1 Good Practice Recommendations The Registered Provider should ensure that the statement of purpose and service user guide indicate the date of the last review/update so readers can ascertain whether the information is current. The Registered Provider should ensure that service user risk assessments are improved to provide detailed guidance to staff. The Registered Provider should ensure that more information is gathered about what is important to the person now and in the future. This should include their life history,interests, preferences, routines, social activities, relationships, possessions and places in order to assist the development of individualised activities. The Registered Provider should introduce care plan objectives with targets, actions,timescales and responsibilities in order to assist with monitoring and evaluation. The Registered Provider should ensure that service users receive appropriate support with their appearance. The Registered Provider should ensure that where service users experience difficulties with expression or understanding, detailed records are kept of how the person communicates, what is happening at the time, what it means and how staff must respond. The Registered Provider should ensure that specific activities are included in the social and activity programmes to ensure service users with dementia or mental health issues are assisted to maintain or develop skills, and individuals are supported to maintain and or develop links with their community, as appropriate. The Registered Provider should ensure each service user has a designated amount of individual activity time each week and a record is kept of what has taken place. The Registered Provider should develop the keyworker system to ensure it provides maximum benefit to service users. G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 27 2. 3. OP7 OP7 4. OP7 5. 6. OP8 OP8 7. OP12 8. 9. OP12 OP12 Manor Park 10. OP15 11. 12. 13. 14. OP18 OP19 OP20 OP21 The Registered Manager should gather more detailed information from each service user about food likes and dislikes and ensure there is a sufficient variety of dessert choices on the menu to suit service users needs. The Registered Provider should ensure that staff are provided with risk assessment training appropriate to their role. The Registered Provider should take steps to make the main lounge more attractive. The Registered Provider should arrange suitable sleeping facilities for staff. The Registered Provider should change the toilet flush in the upstairs bathroom to make it easier for service users to use. Manor Park G52-G02 S25632 ManorPark V232272 260405 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 46 Loman Street London 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. 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