Inspection on 17/11/05 for Manor Place Nursing Home

This inspection was carried out on 17th November 2005.

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 Place Nursing Home 31/03/08

Manor Place Nursing Home 06/09/07

Manor Place Nursing Home 16/05/06

Manor Place Nursing Home 27/06/05

Manor Place Nursing Home 13/12/04

Manor Place Nursing Home 13/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Manor Place Nursing Home 116 Church Lane East Aldershot Hampshire GU11 3HN Lead Inspector Tim Inkson Unannounced Inspection 17th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Manor Place Nursing Home Address 116 Church Lane East Aldershot Hampshire GU11 3HN 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) 01252 319738 01252 327899 Dr Zyrieda Denning To Be Confirmed Care Home 35 Category(ies) of Dementia (35), Old age, not falling within any registration, with number other category (35) of places Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Manor Place is a 35-bedded care home with nursing providing care and support for older persons and is owned solely by Dr Denning. The house is a late 19th Century Victorian mansion, which until the 1980s was St Michaels Vicarage. About 15 years ago a 17-bedded extension was built. The older part of the home has four shared rooms the rest are single rooms and accommodates 18 people. The newer side has 17 bedrooms all with ensuite facilities. There is an extension currently under construction which will offer further accommodation. The new bedrooms will offer en suite accommodation. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two inspections of the home that must be undertaken in the 12-month period beginning on 1st April 2005. It started at 10:00 hours and finished at 16:50 hours. The inspection procedure included; viewing a sample of some bedrooms (9); an examination of some documents and records; observation of staff practices where this was possible without being intrusive; and discussion with some residents (6), staff (4) and a visiting health care professional (1). Other information that influenced the inspection and this report was a preinspection questionnaire completed by the home’s owner on 20th October 2005 and received by the Commission for Social Care Inspection (CSCI) on 9th November 2005. At the time of the inspection the home was accommodating 35 residents and of these 11 were male and 24 were female and their ages ranged from 62 to 95 years. Information provided before the inspection took place indicated that the majority of residents accommodated in the home had enduring mental health problems including cognitive impairments. No resident was from a minority ethnic group. The home’s acting/temporary manager was present throughout the day and available to provide assistance and information when required. A manager from another home owned by the same registered provider was also present during some of the time to provide support for the homes acting manager. What the service does well: The deployment of staff in the home including the number on duty and its mix of skills and experience ensured that staff had the time and were able to provide the help and support that residents needed. This included providing appropriate and sensitive care when individuals died. Residents felt safe and secure and happy that staff could look after them properly. Some of the home’s management systems and procedures were effective and among other things succeeded in promoting the fundamental principles that underpin social care including individuals’ rights to exercise control over their own lives as much as possible. Residents indicated that their bedroom accommodation was good and that it was well maintained and all without exception described it as “comfortable”. The staff valued the support they received from the management and enjoyed working in the home. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 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 Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 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): 3 The home’s admission procedures included good assessments of the needs of potential residents before they moved into the home to ensure that the home could provide the care and support that individuals required. EVIDENCE: The home’s Statement of Purpose included a section that referred to enabling potential residents to choose a care home that meets their needs. It set out a commitment to carrying out “ a needs assessment on each service user prior to admission”. The home had a range of written policies and procedures including it’s “admission procedure” that among other things stated the following: “All admissions, in normal circumstances, will have been pre-planned and information regarding the resident will have been gathered in advance via the assessing team or information from the care manager”. The records of 5 residents were examined and these included copies of detailed assessments that the home had arranged of the needs of the individuals concerned. It was apparent from the documents examined and from discussion with some residents that the needs of potential residents were identified before the persons moved into the home. Where the move into the home of a resident Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 9 had been organised though care management arrangements a copy of the relevant authority’s own assessment of the person’s needs and care plan was available. One resident commented about her admission to the home and said: • “Someone came to see me at home to see what help I needed”. Pre-admission assessments were complemented by more thorough and comprehensive assessments of a resident’s needs when they actually moved into the home. There was documentary evidence that assessments of residents needs were reviewed regularly and revised as necessary when an individual’s circumstances had changed. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 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 and 11 Plans of care lacked clear details of the actions staff needed to take to ensure that residents received the help and support that they needed. The home managed the death of residents sensitively. EVIDENCE: A sample of care plans of 5 residents was examined. A number of issues were identified with in the plans that were examined: 1. The aims and objectives of the plans were mixed up with the interventions that were deemed necessary to achieve the aims e.g. • One intervention stated, “to provide comfort at all times” and another “to maintain oral hygiene”. There were no actual details about how this was to be done. It was suggested that the above examples were the aims and objectives and not planned interventions, as they did not specify what action the staff had to take. 2. There was lack of clarity/specificity in the actions that staff were to take to meet the assessed need of residents e.g. • One intervention stated that the resident was to be “ toileted regularly”. It was suggested that the use of such a term could be widely interpreted. 3. There were areas of some individuals’ needs that were not included in some of the plans that were examined. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 11 • 2 of the care plans examined only included “aims and objectives” and “interventions” concerned with residents’ personal hygiene, mobility and falls. There was no reference to among other things, the nutritional, psychological, and social needs of the individuals concerned. Despite these weaknesses described above, where plans did refer to the specific actions staff had to take and what specialist equipment was needed to provide the support and assistance each person required. Observation and discussion with residents confirmed that individuals received the help they needed and that the equipment was in place as set out in their plans. There was evidence from both the documentation and discussion with residents that wherever it was possible individuals or their representatives had been involved in developing the plans and agreed with the contents. Residents able to converse meaningfully made the following comments about the way the home planned and provided the help that individuals required. • “They look after me very well, they wash and dress me and do all that. They are very efficient”. • “They are not too bad. I need a lot of help, dressing, washing and everything. They are trained in all that aren’t they”? • “…..the staff are very good, they know what they are doing”. • “I need help with getting out of bed and into my chair and everything and they help me with everything…..”. All nursing and care staff spoken to were aware of the care and assistance that the individuals whose records were examined required. The care plans documents examined also included detailed assessments of the potential risks to residents of among other things, pressure sores, malnutrition, and falls. There was evidence that care plans were evaluated and reviewed regularly. The home had developed had a written policy and procedures concerned with managing dying and death. They referred among other things to the need to inform and support relatives and to ensure that “death is approached with great respect…”. The records of a resident who had recently died were examined and it was apparent from notes that had been kept that the comfort of the individual and the support of their relatives had been paramount. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 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): 14 The home had some good procedures in place for ensuring residents could exercise self-determination. EVIDENCE: The home’s Statement of Purpose referred to core values that were regarded as fundamental to it’s philosophy and they included the promotion of residents’ rights and independence. The home had a written policy and procedures about “the management of service users’ money and financial affairs”. It referred to the right of residents to, “retain effective control of their own money”. At the time of the inspection the home’s acting manager said that there were no residents accommodated in the home that managed their own financial affairs. One resident spoken to said, “My son looks after my money for me” and another said that her daughter managed her financial affairs. The home’s Statement of Purpose included reference to the promotion of residents privacy and dignity by among other things, “helping service users to personalise and equip their rooms as they wish”. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 13 A number of residents said that they had brought some items of furniture into the home with them but they it was apparent that they were limited to either television sets or radios. There was however evidence from observation and discussion with residents that they were able to individualise their bedroom accommodation with personal effects such as pictures and ornaments. The home kept records of the television and radio sets that brought by residents into rooms that they occupied. No resident spoken to was aware that they could see records that the home kept about them. The home however had a written policy and procedures about access to files that stated that residents had the right to see their personal records. Sensitive information about residents was kept secure in the home’s office. It is suggested that the home could display and provide information about independent advocacy and information services that residents and their relatives/friends could contact and access if they wanted help. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 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 and 17 The home had satisfactory systems and procedures in place for managing the concerns of residents and their relatives or friends and also for ensuring that residents could participate in the civic process. EVIDENCE: All residents spoken to expressed confidence in their ability to raise any matters of concern or complaints with the home’s staff or manager. The home’s complaints procedure was prominently displayed on a notice board in a communal/public area on the ground floor in part of the home known at the time of the inspection as the “old wing”. It was also set out in the home’s Statement of Purpose. That was included in an information pack or folder made available to all potential and existing residents. The home kept a record of complaints, and details of how they were investigated and the outcome. There had been 4 complaints made to the home since the last inspection of 27th June 2005, and all had been resolved. • “I would certainly complain if I was unhappy about something”. • “I would speak to one of the carers if I had a complaint”. • “If I was unhappy I would speak to the person in charge”. • “I would speak to the manager if I had a complaint as she is very approachable and lovely”. The home had recorded the names of all residents that had been included on the local electoral roll/register in October 2005. One resident spoken to said that she voted in the last election. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 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): 24 and 25 Residents bedroom accommodation was generally well maintained, furnished and equipped for service users safety and specific needs. EVIDENCE: All residents spoken to expressed contentment with the their bedroom accommodation. Comments from residents about these matters included: • “There is nothing wrong with my bedroom, I prefer not to have my heating on. My bed is really comfortable”. • “I like my room. It is comfortable and private. My bed is alright. The light is very bright, it is warm enough”. • “I like my room very much, it’s nice and neat. Its warm enough and I have my top window open. The lighting is suitable”. • “Its alright, they keep it clean”. Bedrooms viewed were all in good repair, clean and well decorated. They varied in size and configuration but were furnished and equipped as expected by Standard 24 of the National Minimum Standards for care Homes for Older People. They were fitted suitable floor covering and doors were fitted with Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 16 suitable locks. All were naturally ventilated and heated by radiators that were covered with guards to prevent residents from the risk of burns. Where a resident required a nursing bed either height adjustable or “profile” beds had been provided for the person concerned. All shared bedrooms viewed were provided with screening to ensure privacy. The nurse call system was tested in one room. It was working and staff responded very quickly when it was activated. The acting manager said that hot water in residents’ accommodation was regulated. The hot water in some wash hand basins and en-suite baths was tested and found to be comfortably warm. The hot water in a wash hand-basin in a WC used by staff was “very hot”. It was suggested that a warning sign be installed to warn people of the danger of scalding. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 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 and 29 The skill mix of the home’s staff was good and they were deployed effectively and in sufficient numbers to meet the needs of service users. Recruitment procedures for new staff were unsatisfactory and failed to ensure that vulnerable adults were adequately protected from the risk of harm. EVIDENCE: The total number of staff employed to work in the home at the time of the inspection was 39, this included 8 registered nurses (1 of whom was on the home’s “bank”) and 23 health care assistants and of the latter 14 (61 ) were qualified to at least National Vocational Qualification (NVQ) level 2 in care or equivalent. Other staff comprised, 2 cleaners, 2 cooks, 3 kitchen assistants and a handyman. The minimum staffing level being maintained in the home at the time of the inspection for registered nurses and care assistants was: Registered Nurses Care Assistants Total 08:00 to 14:00 2 7 9 14:00 to 20:00 2 7 9 20:00 to 23:00 1 5 6 23:00 to 08:00 1 3 4 Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 18 The acting manager stated that 2 health care assistants started at 07:00 every morning and that from 07:00 to 08:00 hours there were 5 health care assistants available to assist residents when they were waking and getting up. It was apparent from discussion with staff that the level of staffing had been increased recently when funding had been made available to provide one to one supervision needed for some residents. Consequently between 08:00 and 14:00 hours, 2 residents were provided with one to one staff support and supervision and between 14:00 and 20:00 hours, 3 residents received this level of staff support. The staff rota was examined and it clearly indicated the names of the staff that were to be responsible for one to one for named residents. The skill mix and deployment of staff during the waking day i.e. 08:00 to 20:00 was such that one registered nurse worked in the each part of the home known at the time of the inspection respectively as the old wing and new wing. Comments from staff, residents and a visiting health care professional about their perceptions of the adequacy of staffing levels included: • “They usually come quickly when I ring my bell. They always have sufficient time to look after me” (resident). • “Staffing levels are alright. In the morning we have 9 and enough also in the afternoons” (registered nurse). • “I think it is fantastic, a good level of staff. It is also very well organised, there are some patients with one to one and compared to hospitals it is fantastic” (student nurse on placement). • “They are very quick if I ring my bell. I think that they are overworked and underpaid…I just know they are. When they help me they are not rushed, but they are underpaid and overworked….” (resident). • “They don’t keep me waiting if I use the bell, they always have enough time to help me” (resident). • “I should think that there are enough” (resident). • “I have been here more than 2 years, I think that there are enough staff. We have enough time to help residents although the mornings can be very busy sometimes” (health care assistant). • “Staffing levels are very good, some staff are on one to one duty. In this unit for residents who are high dependency we have 3 staff in the morning and 2 in the afternoon plus a registered nurse for 17 people. It runs smoothly and it is not too stressful but you can be busy sometimes” (health care assistant). • “I have worked here about 5 months and I have worked in other homes. There are enough of us on duty, we never have big problems because there is one to one care for some who need it” (health care assistant). • “Staffing here is good now, we can ask the owner for extra staff if we need them and she arranged the twilight shift” (registered nurse). • “I think it’s very good here. If I need help I can get it fairly quickly and higher proportion seem to be trained nurses that elsewhere I visit” (visiting health care professional). Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 19 The former/old National Association of Health Authorities and Trusts (NAHAT) issued guidelines concerning staffing levels, before the system for regulating care homes changed in April 2002. These recommended that for a care home with the number of residents and needs as accommodated at Manor Place the minimum staffing skill mix and numbers should be: • From 08:00 to 14:00 at least 2 registered nurses and 5 care assistants. • From 14:00 to 20:00 at least 2 registered nurses and 4 care assistants. • From 20:00 to 08:00 at least 1 registered nurse and 2 care assistants. The records were examined of a member of staff who had started work on 6th October 2005. It was apparent that all the information that must be obtained and pre-employment checks that must be completed before a person can work in a care home and have unsupervised access to vulnerable adults, had not been obtained or completed for this individual. Consequently an immediate requirement was made that all statutorily required pre-employment checks must be completed before a person can work in the home. The acting manager said that the individual concerned would not be allowed to work in the home again until this had been done. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35 and 37 The home’s acting manager was experienced and able to temporarily oversee the functioning of the establishment and the management approach in the home was good. Record keeping was unsatisfactory and failed to fully safeguard residents’ interests. EVIDENCE: There was no registered manager in post at the time of the inspection as the previous manager had resigned shortly before the inspection. The acting manager was a registered nurse and had been working in the home for some 8 months as deputy manager. Her previous experience included working on a specialist coronary care unit in a local hospital and also working in another nursing home for 3 years, where she had been working towards a management qualification i.e. NVQ level 4. Staff spoken to expressed confidence in the knowledge and clinical skills of the acting manager. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 21 The home’s owner indicated in a pre-inspection questionnaire that she would be advertising the post of manager and hoped to make a permanent appointment in 1 to 2 months. Comments from staff about working relationships in the home and including those with the home’s owner were very positive all indicated that they enjoyed working in the home. The staff group were described by individuals as a “very happy team” and the owner as “supportive, approachable and fair”. The home did not manage the financial affairs of any residents but did hold some money for some individuals provided by their relatives or representatives. A sample of the monies and related records for 3 residents were examined. The record for one of these could not be found, but the other 2 were accurate and up to date. A range of statutorily required records were examined during the inspection including the following: • • • • • • • • • Statement of purpose Service users guide Assessments, care plans and related records Complaints Staff Furniture brought by residents into rooms occupied by them Monthly visits to the home by the owner Accidents Money deposited by residents for safekeeping. Not all the records examined were being kept properly as some were not were available, accurate and up to date. There were missing records concerning money held on behalf of residents (see above) and also of monthly visits made by or on behalf of the home’s owner for September 2005. The latter issue had been the subject of a requirement arising from the last inspection of the home on 27th June 2005. Although health and safety matters were not inspected on this occasion as they had been assessed at the last inspection of the home one matter of concern was observed. A number of bedroom doors were open on the first floor of the old wing and they were not fitted with devices that would enable them to close automatically if the fire alarm in the home was activated. A fire door into the lounge on the ground floor of the old wing that was fitted with fire safety equipment was being wedged open. This latter matter was brought to the attention of the acting manager at the time and the wedge was removed. She was reminded that the use of such devices undermines the integrity of fire safety systems. The home’s owner subsequently confirmed that she had spoken to the local fire and rescue service about the fire doors throughout the home, as a review of Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 22 the fire safety system was necessary because the construction a large extension to the building was near completion. She said that she had agreed with the fire and rescue service to implement a programme of replacement and improvement of the existing fire safety system including among other things fitting suitable door closures where none were in place over the next 12 months. Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x X X X X X 3 3 X STAFFING Standard No Score 27 3 28 4 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 2 X 2 X Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure that service users plans are clear, detailed and include all activities of daily living. The registered person must ensure that no new member of staff is employed to work in the home until all statutorily required checks have been completed in respect of that person. The registered person must ensure that all statutorily required records are accurate and up to date including those concerned with; (1) money held on behalf of residents; and (2) copies of reports of monthly visits to the home by or on behalf of the owner. (Previous timescale of 30/06/05 not met) Timescale for action 31/01/05 2 OP29 19 17/11/05 3 OP37 17 31/01/05 Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Manor Place Nursing Home DS0000012150.V267407.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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