Inspection on 27/04/06 for Manor Park

This inspection was carried out on 27th 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 Park 04/09/08

Manor Park 31/07/07

Manor Park 19/10/05

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 10:00 27 & 28th April 2006 th 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.V292414.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 Park DS0000025632.V292414.R01.S.doc Version 5.1 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 02082979963 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.V292414.R01.S.doc Version 5.1 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 19th October 2005 Date of last inspection Brief Description of the Service: Manor Park is a care home providing personal care and accommodation 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. The current range of fees for the home are £420-£480. This information was provided to CSCI in February 2006. Additional charges are made in respect to activities, hairdresser, transport if provided and other sundries such as toiletries and newspapers. Prospective service users and relatives are given information about the service on an initial visit to the home. It states in the service user guide that copies of CSCI inspection reports are available on request. Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out over two days and included speaking to five service users and one relative. The registered manager was present for the duration of the inspection process and the operational manager was also present for part of the process. Other inspection methods used included speaking to three staff members, inspection of records and a full tour of the premises was undertaken. What the service does well: What has improved since the last inspection? The home ensures that prior to accepting service users that a full needs assessment is obtained from referrers as well as carrying out their own assessment to ensure they can meet the needs of the individual. These are also used to draw up a plan of care with service users. Care plans are being reviewed more regularly and also signed by service users indicating that they are being involved in the care planning process. There have also been improvements in the risk assessments although these still need to be more comprehensive. Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 6 Recording within service user plans has improved particularly in respect to the personal care being received by service users and activities service users are doing. The registered owner has submitted plans for permission to make improvements to the environment of the home and to improve access for service users living within the home by installing a passenger lift. There have been improvements in the recruitment practice of the home. 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 Park DS0000025632.V292414.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 Park DS0000025632.V292414.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): 1,2,3, 4 &5 Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Current and prospective service users still do not have access to an updated Service Users Guide that contains all the required information. Service users have not been issued with contracts/statements of terms and conditions with the home. All service users who have moved into the home have had their needs assessed. Service users needs are well met by the staff working within the home. Prospective service users and /or relatives where possible have an opportunity to visit then home prior to admission. EVIDENCE: Subject to a previous requirement an updated service user guide for current and prospective service users that includes all the information required by regulation and the relevant standard was not available for inspection. It was reported by the operational manager this in the process of being drafted. The Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 9 home has a statement of purpose that was inspected at the last inspection that does meet with regulation (See Requirements). Current service users have not been issued with a statement of terms and conditions with the home although it was reported this is in the process of being drawn up (See Requirements). There was evidence from the service user plans inspected that a full needs assessment has been obtained for all service users who have been admitted to the home since the last inspection meeting the previous requirement stated in this area. Service users needs are well met by a staff team that both individually and collectively have the skills and experience to deliver the services and care the home offers to provide. One of the registration categories of the home includes mental disorder. Following the admission of a service user to the home with a diagnosis of mental disorder whose behaviour the staff found to be very challenging a requirement was stated at the inspection held April 2005 that the staff should receive specific training in this area. The service user did not remain at the home but was found an alternative placement. The requirement had not been met at the last inspection and was restated. However, at this inspection following discussion with the registered manager and the operational manager a decision was taken for this requirement not to be repeated as staff have received relevant training in how to manage difficult and challenging behaviour. Also, prior to this situation and since this occurred the staff have not experienced any problems in meeting the needs of service users with a mental disorder living at the home. It was reported that where possible prospective service users, their relatives and friends are invited to visit the home. Service users move in on a trial basis before they make a decision to stay. This was evident from the service user plans inspected for those service users most recently admitted to the home both of whom have had an initial review carried out with them by the local authority to discuss how they have found living at the home before their placements were made permanent. Manor Park DS0000025632.V292414.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): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans need to address personal and social care needs in more detail and risk assessments need to be more comprehensive. Service users health care needs are comprehensively met. Service users are generally protected by the home’s procedures for dealing with medicines but the policy needs to be reviewed and updated. Service users reported that they are treated respectfully and staff maintain their privacy. EVIDENCE: Four service user plans were inspected. A previous requirement that the plans must be based upon the full needs assessment obtained by the home has been met. There is still not sufficient detail given within the plans on action to be taken by care staff to ensure that the personal and social care needs of service users are met. Some needs are identified but have not been addressed within the care plan (See Requirements). Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 11 All plans inspected have a risk assessment in place that address the risk of falls and control measures to reduce this risk are specified. However, other risks presented by service users have not been addressed within risk assessments. This shortfall has the potential to adversely affect the welfare of service users. It became evident in a discussion with the Registered Manager that staff may require some training in this area. Care plans inspected have been regularly reviewed including annual reviews by social services taking place. Also, all care plans except one that belonged to a service user that has recently been admitted have been signed indicating their involvement in the drawing up of the care plan. However, risk assessments have not been regularly reviewed (See Requirements and Recommendations). It was clearly evident from service user plans that health care needs are comprehensively met by staff within the home and that the home regularly liaises with a range of health care professionals such as G.P’s, district nurses, dentists, opticians, chiropodists amongst others. Monthly weight monitoring has taken place and needs in respect to pressure area care and continence have been addressed. A sample of Medication Administration Record (MAR) sheets was inspected and no errors were identified. It was reported by the Registered Manager that all but two of the care staff have completed a Safe Handling of Medicines course. The home’s medication policy is in need of being updated. It has not been reviewed since 2002 and needs to be more comprehensive. Specifically it was noted that it does not include that medication needs to be retained for seven days in the event of a death of a resident nor is this included in the home’s death and dying policy. In addition, the temperature of the fridge used for cold storage of medication is not being monitored or recorded (See Requirements). None of the present service users take responsibility for their own medication. There was evidence that the registered manager has previously consulted with service users and their relatives about self- administration but none of the service users living at the home at that time nor their relatives were willing to consider this option. However, it is advised that this issue should be individually discussed and assessed with any future service users admitted to the home and a record kept of the outcome (See Recommendations). Staff were observed treating service users with warmth and respect at all times during the inspection. Staff addressed service users as they prefer and those spoken to confirmed that staff respect their privacy at all times. One service user commented that staff “always knock before entering my room” whilst another stated the staff “treat you well”. All service users were observed as being very well groomed and dressed and service users spoken to confirmed they choose what they wear rather than staff. Manor Park DS0000025632.V292414.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): 12,13,14 &15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not presently engaged on a regular basis in structured activities that match their personal expectations and preferences. Service users are encouraged to maintain contact with family and friends. The home does generally support service users to make their own choices and exercise control over their lives but information on external advocates needs to be made available. Service users are not presently receiving a sufficiently varied menu to ensure a balanced diet. EVIDENCE: A previous requirement that individual and group activities are undertaken on a regular basis and that service users are consulted and feedback obtained on individual and group activities has not been met. Although, there has been an improvement in staff maintaining individual activity records it was evident from inspecting these and speaking to service users that activities that meet service users’ personal interests and preferences and also in respect to the home’s weekly activity schedule have only been carried out occasionally. Two service users spoken to stated they would like to go out more. Also, some of the individual activities that have been recorded include watching television and Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 13 reading. These are every day past times that do not require any staff involvement or interaction. There was evidence that the home has organised a series of reminiscence sessions organised by a worker from the Pump House Museum. It was reported by the registered manager that all the service users took part in the sessions although some were initially reluctant and the written evaluations of the sessions demonstrated that service users clearly enjoyed being involved and found them interesting and stimulating. Although, it is very positive that the home organised these sessions and two staff since the last inspection have received training in reminiscence as previously recommended, more efforts need to be made to ensure that service users are regularly given opportunities to be involved in structured activities both on an individual and group basis within and away from the home (See Requirements). In respect to religious observance generally service users are supported to attend church and there are visits to the home from the local clergy. It was evident from speaking to service users and a relative that visitors are encouraged and welcomed by staff at the home and service users are able to see visitors in private in their own rooms. Observations and also discussions with service users confirmed that they are able to exercise choice and be as independent as possible. One service user described themselves as being “free” in terms of what they are allowed to do in the home whilst other service users described that they are able to get up and go to bed when they choose. There was also evidence from customer satisfaction surveys carried out by the home that service users are aware that they can see their personal records. However, the home needs to provide information to service users about external advocacy services to enable them to access independent advice/representation if required (See Recommendations). Lunchtime was observed and it was very relaxed and unhurried with service users being given plenty of time to eat. The home has a four- week rolling menu that is varied and offers a choice of meals but the cook also keeps a separate record about what is cooked for service users in a diary. It was evident from this that what is on the menu is not always being offered to service users. Subsequently, it was not clear from this record that service users were being offered a choice of meals. There was also repetition of meals. For example, in the week that the inspection was held service users were given virtually the same lunch and the same supper on three occasions. Feedback from service users was varied about the food and although it appeared that they were generally happy about the quantity it was reported by two of the four service users spoken to that they are not always given information in advance about meals to be provided. Instead, they are informed on the day and asked if they would prefer something different (See Requirements). Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 14 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): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are informed about the complaints policy. Service users are protected form abuse. EVIDENCE: The home ‘s complaints policy is simply written and includes all the necessary information about the process such as stages and timescales within which complaints will be dealt with. The policy is accessible with a copy on display on each floor. In addition, there was evidence from resident meetings that have been held that service users have been informed about the policy and encouraged to raise any issues in relation to the home about which they have concerns. The home does however need to provide service users information about external advocates to act on their behalf if needed (See Standard 14). The home has a complaints log. There have been no complaints made since the last inspection. Subject to a previous requirement the home has reviewed and updated the adult protection policy, which is now very comprehensive. Staff spoken to had knowledge of adult protection procedures and awareness of adult abuse. The majority of staff have undertaken training in this area. The home has not had any adult protection investigations since the last inspection. Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 15 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 &26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home provides a safe and homely environment for service users and concerns about access within the building for individuals with deteriorating mobility are to be addressed. The home has sufficient lavatories and washing facilities for service users. Although access to the front of the building is not adequate, the home has put measures in place to ensure the safety of service users. The home is clean and hygienic. EVIDENCE: Overall, the home provides a safe, homely and well-maintained environment for service users. However, concerns have been raised at previous inspections about access issues inside the building. 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 and at present the home does not have the facilities to be able to support service users as their mobility and health needs Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 16 increase. At this inspection it was reported that this matter is to be addressed. The registered provider is awaiting planning permission to commence work on the home that will involve installation of a passenger lift as well as extending the home to include more bedrooms. It is hoped that building work will commence before the end of the year. In the event that planning permission is obtained it is advised that prior to the work commencing that service users and relatives are informed and consulted about the proposed changes. (See Recommendations). Communal facilities inside and outside the home are generally safe and comfortable. The home has a separate lounge and dining area that are homely and the furnishings are domestic in character. There is access from the dining area to a large garden at the rear, which has decking and a sheltered area where service users can sit. The home has met a previous requirement of finding alternative storage for hoist equipment. In respect to staff sleeping in the registered owner has agreed to make one of the bedrooms on the third floor the staff sleep in room temporarily. This meets a previous requirement that alternative arrangements need to be made for staff due to the inadequate facilities that are presently in place. It was reported that improvements to staff facilities are also included within the proposed changes to the home. The home has sufficient toilets and bathrooms and the previous requirement that the work on the toilet on the first floor is carried out has now been met. None of the bedrooms at present have en-suite bathroom/toilet facilities. It was reported that work to install a ramp at the front of the building is to be completed as part of the other building work that it is hoped will be commenced by the end of the year. It was noted that the problem of service users being able to access the front entrance has been addressed within individual service users risk assessments. Consequently, the previous requirement in respect to the ramp is not to be restated. In respect to other aids and equipment the home provides grab rails in corridors bathrooms and toilets. There is also a call system in all service user bedrooms and toilets and bathrooms. On the day of the inspection the home was clean and hygienic with no offensive odours being noted. Laundry facilities are sited in the basement and washing machines have the specific programming ability to meet disinfection standards. Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 17 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): 27,28,29 &30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff on duty with the required skills to meet the needs of service users. There are sufficient numbers of staff that are qualified to NVQ Level 2. Service users are protected by the home’s recruitment practice. Staff are given access to training to ensure they can carry out their work to a competent level. EVIDENCE: The home’s rota was checked and accurately reflected staff on duty the day the inspection was carried out. There are two care staff on duty in the morning /afternoon and afternoon/evening shifts with one care worker sleeping in and one who works a waking night. At present approximately 60 of the care staff working at the home are qualified to National Vocational Qualification (NVQ) Level 2 in care. Two care staff have recently left the home that were qualified. This still meets with requirements that at least 50 of staff should be qualified by the end of 2005. Four staff files were inspected including those of two staff members that have recently started working at the home. These were found to include all the necessary documents required by regulation. A previous immediate requirement issued to the home at the last inspection regarding a staff Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 18 member who was working at the home without an Enhanced Criminal Record Bureau check was promptly addressed. Staff are trained and competent to do their jobs. There was evidence that new staff are being fully inducted. The home has drawn up an annual training plan and individual records of staff training are kept. Evidence of training completed was also seen on staff files. Subject to a previous requirement, annual appraisals have also been completed with staff. Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 19 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 &38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the home. The home is well run and managed by a person fit to be in charge. 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 financial interests are safeguarded. Staff are not receiving supervision regularly. The health, safety and welfare of service users and staff are protected. EVIDENCE: The registered manager has relevant experience and is currently undertaking the Registered Manager Award and NVQ 4 in care and management, which she is due to complete in June 2006. She recently passed a Supervisory Management course with distinction demonstrating willingness to update skills Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 20 and knowledge. In addition, the registered manager is now receiving support from the operational manager. This has seen an improvement in the overall administration and management of the home. Discussions and observations of interactions between staff, service users and the registered manager demonstrated that there is a very positive and inclusive ethos within the home and that the registered manager is approachable, supportive and very committed. Feedback from staff confirmed that the registered manager welcomes and listens to ideas and contributions form staff. In relation to quality assurance, evidence was seen that the home has used customer satisfaction questionnaires in 2005 as part of self-monitoring. Service users, relatives and professionals involved in the home, completed these. A report summarising the results of the questionnaires was written and a meeting was also held to feedback the results of the survey. The registered manager reported that another survey is due to be completed shortly for this year. The operational manager ensures monthly provider reports are completed of which evidence was seen and resident meetings are held although these need to be carried out on a more regular basis. The home also needs to draw up an annual development plan for the home (See Requirements). The home manages the personal allowance for all service users presently living within the home. Each service user has their own individual petty cash account in which all transactions are recorded and receipts are kept. A previous requirement that financial records should be accurately maintained in that transactions should be signed for by service users and a staff member is considered to have been met. This occurs when monies are directly issued to service users from their personal allowance, which is acceptable given receipts for all other transactions are obtained. Any monies to be paid into service users personal accounts that are managed by the home by relatives/friends are recorded in a separate book and are signed for by the staff member receiving the money and the relative. The registered manager also carries out a self- audit fortnightly of service users’ finances. Subject to a previous requirement records inspected indicate that supervision is still not being carried out on a regular basis. Records looked at showed that appropriate discussion and topics are covered. It was noted that for one staff member the issue of equalities was raised to reinforce the home’s equal opportunities policy that all service users should be treated fairly and receive an equality of service. It was advised this should be addressed and reinforced with all staff within supervision and be discussed as an agenda item within supervision on a regular basis (See Requirements and Recommendations). Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 21 There was ample evidence that the home does promote the health, safety and welfare of service users and staff. Staff have had training in first aid, food hygiene and manual handling. A sample of maintenance certificates were inspected and found to be up to date including those for the electrical systems and equipment, the gas boiler and central heating system, call system and hoist and fire equipment. Monthly risk assessment checks are carried out for the whole building and there is an up to date fire risk assessment in place. Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 22 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 Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 Page 23 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 X 3 Manor Park DS0000025632.V292414.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 OP1 Regulation 5 (1) Requirement Timescale for action 31/07/06 2. OP2 5 (1) (b) 3. OP7 15(1) 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. A copy should also be submitted to CSCI on completion. (Previous timescale of 30/04/06 not met) The registered person must 31/08/06 ensure that all service users are issued with a contract outlining the terms and conditions of their stay within the home, which they sign and a copy issued to them and a copy kept on their individual files. A copy of the contract must be sent to CSCI on completion. The registered person must 31/10/06 ensure that the care plans set out in detail the action that needs to be taken by staff to ensure that all aspects of DS0000025632.V292414.R01.S.doc Version 5.1 Manor Park Page 25 4. OP7 13(4)(c) 5. OP9 13 (2) 6. OP12 16(2)(m) &(n) 7. OP15 16 (i) personal and social care of service users are to be met. (Previous timescale of 30/04/06 not met) The registered person must ensure that risk assessments address all risk factors presented by the individual needs of service users and action to be taken in respect to minimising the level of those risks identified within service user plans is put in place. Also, that risk assessments should be reviewed monthly as part of service user plans. (Previous timescale of 30/04/06 partially met). The registered person must ensure that the medication policy is reviewed and updated and includes all necessary information to ensure safe handling and storage by staff. This needs to be submitted to CSCI on completion. Also, refrigerator temperatures need to be monitored and recorded to ensure cold storage of medication is kept within 2 – 8oC. 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 inside and outside the home. Further, that individual and group activities are undertaken on a regular basis. (Previous timescale of 30/04/06 partially met). The registered person must ensure that service users are provided with a varied menu that DS0000025632.V292414.R01.S.doc 31/10/06 31/07/06 31/10/06 31/10/06 Manor Park Version 5.1 Page 26 8. OP33 24&26 9. OP36 18(2) provides a nutritious and balanced diet. That service users are given information in advance about the menu and they are offered a choice of meals. Also, that any changes to the menu are recorded. The registered person must 31/10/06 ensure that as part of selfmonitoring and quality assurance that resident meetings are held regularly. Also, that an annual development plan is put in place. The registered person must 31/10/06 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 timescale of 30/04/06 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 OP7 OP9 Good Practice Recommendations The registered person should ensure that staff undertake risk assessment training to enable them to carry out more effective risk assessments with service users. The registered person should ensure individual assessments with new service users are carried out on whether they can take responsibility for taking their own medication and this is recorded. The registered person should access information on independent advocacy services and make this available to service users. The registered person should arrange for consultation to take place around the proposed changes to the home once planning permission has been obtained for building work to go ahead. The registered person should ensure that equalities and DS0000025632.V292414.R01.S.doc Version 5.1 Page 27 3. 4. OP14 OP19 5 OP36 Manor Park diversity is kept as an agenda topic for supervision to ensure staff have a common understanding of the home’s approach to equalities and for ways they can use equalities and diversity in their work with service users including trying to raise service users’ awareness of the issue. Also, to explore other ways the home can ensure it works with these issues effectively. Manor Park DS0000025632.V292414.R01.S.doc Version 5.1 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. 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