Inspection on 31/07/07 for Manor Park

This inspection was carried out on 31st July 2007.

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 27/04/06

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 Key Unannounced Inspection 31st July 2007 10:00a 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.V341531.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 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 852 2407 0208 297 9963 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.V341531.R01.S.doc Version 5.2 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, 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 14th February 2007 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. These rooms are no longer in use as it was recognised that they were difficult to access. There is an extensive garden to the rear of the building. The current range of fees for the home are £420-£490. This information was provided to CSCI in June 2007. 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. At the time of the inspection the home was not fully occupied with eight residents living at the home. Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day. The registered manager was present when the inspection took place and was involved in the inspection process. As many of the residents suffer from dementia or have memory impairment some of the relatives of those living at home were contacted following the inspection and two were spoken to. One member of the care staff team was also consulted during the inspection. Other inspection methods included inspection of records and a tour of the building. What the service does well: What has improved since the last inspection? The home only received three requirements at the last random inspection that was held in February 2007 of which two at this inspection were identified as met. The home has taken measures to ensure the home’s service user guide is accessible to residents, relatives and visitors. Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 6 Improvements had been made to ensure that individual risks presented by residents’ needs had been addressed within their care plans and these had been reviewed monthly. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 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.V341531.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Standard 6 is not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and relatives had access to the information they need to make an informed decision about the home. Residents’ needs had been fully assessed prior to them moving into the home. EVIDENCE: The home had recently updated the statement of purpose and service user guide to include all the information required by regulation including information about fees. However, at the random inspection held in February 2007 it was identified that the revised service user guide had still to be issued to residents. At this inspection a copy of the service user guide had been placed in each residents’ personal file. In addition, there was evidence of measures being taken to place copies of the home’s statement of purpose and service user guide in the entrance foyer of the home making these documents accessible to both residents and relatives. Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 9 The personal files of four of the residents were looked at, one of which belonged to a resident that had only moved into the home in the past two weeks. All the files included evidence that a full needs assessment had been obtained prior to their admission into the home to ensure that the home would be able to fully meet their individual needs. The home also has its own pre – admission assessment. Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 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. 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. There was an individual plan in place for all residents that addressed their health, personal and social care needs but not all fall risk assessments had been reviewed. Residents’ health care needs had been met. Staff had consistently adhered to the home’s medication policy and procedures to ensure residents were protected. Residents were treated respectfully and their right to privacy was maintained. More information needs to be obtained about residents’ personal wishes and instructions on death and dying. EVIDENCE: The personal files of four residents were inspected. The home uses the standex format for care plans. All the residents including one that had only moved into the home two weeks prior to the inspection had a care plan in place. These had addressed their health and personal care needs in sufficient detail and individual preferences on personal care and daily routines had been specified. There were some details on social care needs and the home was also in the process of completing life review forms with residents and relatives to gather more information about residents’ interests, hobbies and other information Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 11 relating to this area. All the care plans apart from the one belonging to the resident that had recently been admitted had been signed either by the resident themselves or a relative on their behalf. The capacity of one of the residents who had signed their care plan was queried with a member of the care staff team and it is advised that where residents may experience confusion and memory impairment a relative or an independent representative signs on their behalf. For three of the residents there was evidence that falls risk assessments had been completed. However, one was still to be drawn up for the newly admitted resident and it was noted that regular reviews of fall risk assessments for other residents had not been carried out. This needs to be addressed. In relation to a previous requirement that all risks presented by the needs of individual residents need to be addressed and reviewed this had been met. There was evidence that individual risks had been addressed within residents’ care plans that had been reviewed on a monthly basis as specified within National Minimum Standards (NMS) (See Requirements and Recommendations). There was evidence within personal files that residents’ health care needs had been well met. A record had been maintained for individual residents of contact they have had with a range of health professionals including GP, district nurses, podiatrists and chiropodists, dentists and also community psychiatric nurses and psychiatrists. Residents’ care plans also had addressed both physical and emotional health needs. In respect to medication, it was identified at a random inspection held in February 2007 that the home had addressed a previous requirement to update the policy and procedure to cover all areas of handling, storage and administration of medication. At this inspection, a sample of medication records were checked and all were found to be accurate. The home has visits from a community pharmacist and the report of the last visit undertaken on 20/06/07 was seen. Overall, the report was positive about how the home had managed medication. Only three recommendations were specified, which the home had acted upon or were in the process of addressing. On the day the inspection was held the home’s GP visited to carry out a review of all residents’ medication. However, it was noted in checking medication records that where the GP had made changes to individual residents’ medication these had not been signed off by the GP. It advised care staff should try to ensure that this is addressed at the time by the GP. Furthermore, in respect to a previous recommendation that prospective and newly admitted residents should be assessed as to whether they can take responsibility for their own medication and that this is recorded as part of a pre –admission assessment, their care plan and/or risk assessment this had still not been carried out (See Recommendations). Observations of interactions between care staff and residents were observed as warm and respectful and it was evident that residents felt relaxed and Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 12 comfortable with care staff. Where residents were assisted with toileting it was observed that their privacy was always maintained. Furthermore, all residents were well dressed and groomed. One relative who was spoken to also confirmed that their mother was always well presented. Some information about residents’ death and dying wishes had been obtained but this tended to be very brief and only specified if there was to be a burial or cremation or that relatives were to take responsibility for arrangements. It is advised that residents’ be sensitively consulted about whether or not they have any particular wishes or instructions they would like followed at the time of death and dying (See Recommendations). Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Previous improvements in respect to activities had not been sustained and although some activities were carried out with residents these need to be more varied and more structured. Residents were supported to maintain contact with family and friends. Residents had been supported to exercise choice and control over their lives. Residents receive a varied and appealing diet that is nutritious. EVIDENCE: At the last random inspection held in February 2007 it was identified that improvements had been made in the range of activities and opportunities for social interaction provided to residents. There was evidence that the home had organised trips for some residents to go to the Pump House museum, which specialises in reminiscence and also to go to the theatre. In addition, outside entertainers had been brought into the home and the Pump House had come to do a reminiscence session with residents, the evaluation of which was very positive and demonstrated residents had enjoyed it. Finally, individual activity records indicated residents had been involved in a number of activities within the home including sing a longs, listening to old time music, karaoke, bingo and exercises and that key workers had spent individual time with residents Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 14 talking to them and one resident was supported to continue his hobby in making model ships. At this inspection it was evident that these improvements had not been sustained. Individual activity records did demonstrate that residents had been encouraged and involved in some activities such as doing simple exercises, listening to old time music, bingo but these had not appeared to have always been held regularly. The home does not have a structured activities timetable in place. There was evidence that key workers were spending some individual time with residents doing reminiscence work or just chatting generally but other activities recorded included watching TV, reading or walk in the garden. Positively the home has a mobile library that visits the home making books accessible to residents that are of interest to them. However, more structured group activities need to be organised by the home as well as bringing in outside entertainment to give residents more opportunities to socially interact with one another and others inside and outside the home if appropriate (See Requirements). It was evident from residents’ personal files that included a record of relatives’ visits and contact that links with family and friends had been supported by the home. Relatives spoken to following the inspection stated they had always felt welcomed by the staff at the home and one relative commented, ‘I have never ever felt that I have turned up at the wrong time’. In addition, to maintain contact with the local community, a vicar visits the home every Wednesday to see those residents that have requested or expressed a wish to do so. There was evidence that the home is conducted so as to support residents’ capacity to exercise personal autonomy and choice, for example they are able to bring in personal possessions with them when they move into the home and there was evidence of this in inspecting individual residents’ rooms. Residents were also observed as being able to choose to become involved in activities or to spend time alone in their room as they wished. Following previous recommendation information regarding independent advocacy services had been obtained and had been included within the home’s complaint policy. The home has a four -week rolling menu that offers a good variety of meals that are well balanced and nutritious. The registered manager reported that the cook always informs residents what is to be cooked for lunch on each day and asks if they would like something different. The meal for the day was also written up on a board in the dining room for residents’ information. A lunchtime was observed and the inspector was also offered to eat lunch with the residents. The food was hot and tasty, well presented and nutritionally balanced. Furthermore, residents were allowed to eat their food in a relaxed and unhurried environment. All residents appeared to enjoy the meal and those that were asked confirmed this. Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 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. 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. The home had a robust complaints policy in place and it had been made accessible to residents and relatives. Measures had been taken by the home to ensure residents were protected from abuse. EVIDENCE: The home’s complaints policy is simply written and includes all the necessary information about the stages and timescales within which complaints will be dealt with. The policy is accessible to residents, relatives and any other visitors in that a copy of the policy was seen on display in the entrance hall of the home although this could be written in larger print for easier visibility. As mentioned in respect to Standard 14 information regarding advocacy had been added to the complaints policy. The home has a complaints log to record all formal and informal complaints but no complaints had been received by the home since the last inspection. Relatives spoken to following the inspection stated they would speak to the manager or staff if they had any concerns about the home (See Recommendations). In respect to adult protection, the home had drawn up a comprehensive policy and procedure. All staff apart from those most recently employed by the home, a member of the care team and the cook had completed training on adult abuse/ protection provided by Lewisham Partnership. There had not been any adult protection investigations carried out in relation to the home since the last inspection. Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21,24 &26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a homely environment for residents but concerns about access from outside into the building and also within the home for individuals with deteriorating mobility needs to be addressed and some re-decoration of the home is required. The home has ample communal space but outdoor communal facilities need to be improved. Not all the toilet and washing facilities in the home were of a sufficient standard to safely meet the needs of the residents. Residents’ bedrooms are comfortable although the furniture looks dated. The home was clean and hygienic. EVIDENCE: The home provides a homely environment for residents but it was noted that communal areas of the home were in need of some re-decoration and where new fire doors had been installed these were in need of being painted. In addition, previous inspections have raised concerns about access issues outside and inside the home resulting in the needs of residents not being able Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 17 to be fully met as their mobility and health needs increase. The home does not have any disabled access to the home from outside, which is in contravention of the Disability Discrimination Act 1998 and inside the home although there is a chair lift to the first floor, there are still five stairs that residents have to be able to climb before the rooms and other facilities on that floor can be accessed. There are a further two bedrooms on the second floor but these have been assessed not to be appropriate for residents’ use due to the stairs that would have to be managed. At present the home does not have any residents that are wheelchair bound although it was reported that two of the residents do need wheelchairs to be able to go out and there are residents that can only mobilise with the use of a Zimmer frame living at the home. The registered provider did previously state that planning permission was to be sought to install a ramp at the front of the building and also to extend the home to include a passenger lift and further bedrooms. Yet, the registered provider has since informed CSCI that these plans are no longer to be pursued due to financial constraints. However, to ensure the needs of the residents living at the home can be met by the home the access issues must still be addressed and further clarification on how the registered provider intends to do this must be provided to CSCI (See Requirements). There is ample communal space within the home. There is a large lounge that is bright and spacious and a separate dining area. Both have furnishings that are domestic in character. The garden that is large and generally well maintained can be accessed via French doors from the dining room where there is an area with decking and also a sheltered area where residents can sit away from the sun. However, the furniture used in the garden largely consisted of old chairs once used inside the home rather than proper garden furniture. It was not appropriate for outdoor use and looked shabby. Alternative garden furniture needs to be purchased (See Requirements). The home has a sufficient number of toilets and washing facilities for residents but it was identified that the bath downstairs could not be used as there was an old hoist attached to the bath that had not been replaced or repaired. This bathroom also contained a shower that was in use but concerns were raised with the registered manager, as instead of the shower having a proper chair for residents to be able to sit down, a plastic garden chair was being used. Due to the health and safety risk this posed to residents an immediate requirement was issued to the home that the garden chair should immediately be removed and that a more appropriate shower facility should be provided to meet the needs of the residents within the next three months. The registered provider responded to the immediate requirement within the timescale specified informing CSCI that as a temporary measure a mobile disabled shower chair had been purchased and that measures would be taken to improve the shower facility. In addition, it was noted that the paint on the walls of the downstairs toilet was flaking and this also needs to be looked into and addressed (See Requirements). Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 18 Residents’ bedrooms were generally comfortable and suitably personalised although the furniture looks dated and could be renewed (See Recommendations). The home was clean and hygienic on the day the inspection was held and free from any offensive odours. Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were sufficient numbers of staff on duty with the required skills to meet the needs of the residents. The home has met the required target that 50 of the care staff should have achieved a relevant qualification. Residents have been protected by the home’s recruitment practices. An annual training plan was not in place and not all mandatory training had been updated as required. EVIDENCE: The home’s rota was checked and accurately reflected the staff on duty the day the inspection was carried out. There are always two care staff that work during the day and early evening with one care worker sleeping in and one who does a waking night. At present of the nine carers presently employed to work in the home, five have completed a National Vocational Qualification (NVQ) Level 2 and one has also achieved a NVQ Level 3. One of the care team is a qualified nurse who obtained this abroad and it was reported by the registered manager that they were presently in the process of studying for a NVQ Level 4 in Health and Social Care. As a result of the number of care staff that have achieved a relevant qualification the home has met the required target of 50 as specified within the National Minimum Standards (NMS). Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 20 Since the last inspection the home has recruited three staff; two carers and a cook to work at the home. The recruitment records of these three staff were checked and were all found to include the necessary documents and information required by regulation including two references and an Enhanced Criminal Records Bureau (ECRB) check. In respect to training, an up to date training plan detailing all training to be completed by staff over the forthcoming year had not been drawn up and annual appraisals were still to be completed in which training courses for care staff would be identified. The registered manager had been absent from the home for a two -month period and this would have been a contributory factor in these matters not having been addressed. However, it was noted looking at the staff files for those newly employed by the home and also for two of the more established members of the care team that some mandatory training needed to be updated specifically in relation to manual handling. Furthermore, it was identified that the cook had not completed a food hygiene course or infection control. There was evidence that the new care staff were in the process of completing the induction work booklet that is used by the home and meets with Skills for Care specifications and the cook had also received a basic induction (See Requirements). Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 &38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has relevant experience and is in the process of completing the Registered Manager’s Award to ensure the home is well run. Generally the home is run in the best interests of residents but the home must ensure that an annual development plan is completed following the views of residents being sought. Residents’ finances are effectively safeguarded. Generally the health, safety and welfare of residents is promoted and protected but the home must ensure that all documents in relation to fire safety are accessible. EVIDENCE: The registered manager does have relevant experience to be able to run the home effectively and is in the process of completing the Registered Manager’s Award (RMA). As mentioned previously they were absent from the home for a period of two months the reasons for which CSCI were informed but this is not Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 22 to be disclosed within the report. However, evidence from the inspection indicates that despite the registered manager’s absence the home continued to be well managed. In respect to quality assurance the home has carried out customer satisfaction surveys previously. The last survey that was completed was in December 2006 in which questionnaires were issued to residents, relatives and professionals. However, it was noted at the last key inspection held in April 2006 and also at the random inspection that was carried out in February 2007 that the home had not drawn up a development plan reflecting the aims and outcomes for residents based on their views of the home following completion of the surveys. There was still no evidence that this had been completed at this inspection. The registered manager reported that the survey for this year was still to be completed but would take place towards the latter part of the year. Regular copies of monthly provider reports were sent to CSCI up till April 2007. There was no evidence of reports carried out after this point. This needs to be addressed and copies of the reports should be kept within the home. Also, resident meetings had not been held on a regular basis since the last inspection. The last minutes that were available for inspection were for a meeting held in February 2007 (See Requirements). The home manages the personal allowance for all residents living at the home and there are robust procedures in place to ensure these are effectively managed. Each resident has a book in which all transactions are recorded and receipts are also kept. Fortnightly audits of residents’ finances are carried out. A sample of residents’ finances was checked and all were found to be in order. There was evidence that the health, safety and welfare of residents had generally been promoted and protected, for example monthly health and safety checks had been carried out of the building. There were also up to date maintenance certificates in place for gas, electrical wiring, portable electrical appliances, and hoist and fire equipment. The home had an inspection from the LFPEA earlier this year. Some recommendations were made that included: all the doors within the home needed to meet with fire regulations, maintenance work of the emergency lighting had to be carried out, there should be clear fire procedure instructions that should be followed and a fire risk assessment should be drawn up. There was evidence all these had been addressed although a copy of the fire risk assessment could not be located on the day of the inspection. Furthermore, fire alarm call points had been tested weekly and regular fire drills had been carried out that noted the time the drill took place but did not specify the time it took to complete the drill. It is advised a note of this is made within the records maintained (See Requirements and Recommendations). Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 1 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 3 X 2 X 3 X X 2 Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 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 OP7 Regulation 12 (1) Requirement Timescale for action 31/12/07 2. OP12 16(2)(m) 3. OP19 23 (1) The registered person must ensure that all residents have a falls risk assessment completed as soon as possible after they move into the home to ensure their needs can be met and their health and safety is maintained. Also, that these are regularly reviewed as part of residents’ care plans to reflect any changing needs. The registered person must 31/12/07 ensure that all residents are provided opportunities for social interaction inside and outside the home where appropriate and that more structured group activities are arranged. The registered provider must 30/11/07 provide clarification on how the issues of access both inside and outside the home are to be addressed, specifically that a ramp is needed at the front of the building and access up to the first floor within the home needs to be improved, to ensure that all the needs of residents living within the home can be safely met. DS0000025632.V341531.R01.S.doc Version 5.2 Manor Park Page 25 4. OP19 23(2)(d) 5. OP20 23(2)(c) 6. OP21 23(2)(n) 7. OP21 23(2)(n) 8. OP21 23(2)(b) The registered provider must ensure that the communal corridors and doors are painted maintaining the decoration of the home to a reasonable standard. The registered provider must ensure that furniture specifically for use in the garden is purchased to be used by residents. The registered provider must ensure that immediate action is taken to remove the garden chair being used as a make shift shower chair. A shower that is suitable for the needs of the residents living at the home needs to be provided. This needs to be carried out within the next three months and any delay to this must be explained to CSCI in writing. (Immediate requirement issued 03/08/07. Response received 10/08/07 to inform CSCI that a disabled shower chair had been purchased and measures would be taken to improve the shower facility within timescale specified. Therefore Immediate Requirement has been partially met). The registered provider must ensure that the hoist attached to the bath in the ground floor bathroom is either repaired or removed and a replacement purchased or other suitable equipment to meet the needs of the residents and maintain their safety when being assisted into the bath. The registered provider must ensure that the toilet on the ground floor where the paint is flaking off the walls is redecorated as part of DS0000025632.V341531.R01.S.doc 31/03/08 30/11/07 03/11/07 31/12/07 31/12/07 Manor Park Version 5.2 Page 26 9. OP30 18(1)(c) (i) 10. OP30 18(1)(c) (i) 11. OP33 24 12. OP33 24 13. OP33 26 14. OP38 23(4)(a) maintaining the home in a good state of repair. The registered person must ensure that all staff have an annual appraisal carried out with them to identify any individual training needs and that an annual training plan is drawn up that includes all the training to be completed over the forthcoming year. The registered person must ensure that all staff including the ancillary staff complete training in mandatory topics and this is updated as required. The registered person must ensure that an annual development plan is drawn up for the home that is based on a systematic cycle of planning action-review, reflecting aims and outcomes for service users. (Previous timescale of 31/105/07 not met). The registered person must ensure that as part of selfmonitoring regular resident meetings are held. The registered provider must ensure that monthly provider visits are carried out and copies of the reports are kept within the home. The registered person must ensure that a fire risk assessment is kept within the home that is accessible at all times and available for inspection. 31/12/07 31/12/07 31/12/07 31/12/07 31/12/07 30/11/07 Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 27 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 OP7 Good Practice Recommendations The registered person should try to ensure that where residents experience memory impairment and confusion that their care plans are signed on their behalf by either a relative or an independent representative. 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 try to ensure that where the GP makes changes to individual residents’ medication that they sign the respective medication record sheets. The registered person should try to ensure that residents are sensitively consulted about any personal wishes or instructions they may have with regards to death and dying. The registered person should consider placing the complaints policies on display within the home in larger print for easier visibility for residents, relatives and any other visitors. The registered provider should try to look at renewing items of bedroom furniture for residents as a measure to improve the standard of accommodation to residents. The registered person should try to ensure that the time it takes to complete a fire drill is noted as well as the time the drill took place. 2. OP9 3. 4. OP9 OP11 5. OP16 6. 7 OP24 OP38 Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Manor Park DS0000025632.V341531.R01.S.doc Version 5.2 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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