Inspection on 25/07/06 for Manor Road (30)

This inspection was carried out on 25th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Manor Road (30) 10/01/06

Manor Road (30) 19/09/05

Manor Road (30) 27/01/05

Manor Road (30) 14/10/04

Manor Road (30) 15/03/04

Manor Road (30) 06/09/02

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Manor Road (30) 30 Manor Road Potters Bar Hertfordshire EN6 1DG Lead Inspector Sheila Knopp Unannounced Inspection 25th July 2006 10:00 X10029.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 Road (30) DS0000019455.V305432.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 and Care Homes for Adults 18 – 65*. 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 Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Road (30) Address 30 Manor Road Potters Bar Hertfordshire EN6 1DG 01707 663 908 01707 663 908 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) www.mencap.org.uk Royal Mencap Society Mr Francis G Derrick Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 6 people with learning disability (above 40 years of age). 10th January 2006 Date of last inspection Brief Description of the Service: 30 Manor Road is a two-storey detached house, with six bedrooms. It is located in a quiet cul-de-sac in Potters Bar. The home is within walking distance of the town centre, train station and public transport routes. The home offers support to service users with learning difficulties and mild physical disabilities. Manor Road is a Mencap home. The current fees are £347.27 per week (correct as of 25/07/06). No additional charges are made. Information about the home is contained in the Service User Guide & Statement of Purpose, which would be available from the manager or by contacting Mencap. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced visit to the home by an inspector who spent a total of 5 hours 10 minutes in the home. The inspector spent time with 2 service users in the morning and returned to the home in the afternoon to meet with 4 service users who had been out for the day. The age range of the current service users is 57 – 85 years. This report also includes information provided by service users (6), relatives (5), General Practitioners (3) and a Community Nurse (1) who completed questionnaires sent to them by the Commission. The service user questionnaires were completed with support from staff. Three care plans were reviewed in detail following discussions with the residents and staff. As well as discussion with the manager and deputy manager the inspector interviewed 3 staff and met with the manager and deputy manager. Visits to the home by a psychologist and dietician on the day of inspection provided the inspector with the opportunity to discuss aspects of the service provided at 30 Manor Road with them. Both people were very positive about the quality of life achieved by the service users and the support being provided. Information received about the home since the last inspection on 10 January 2005 has also been reviewed. No concerns have been raised with the Commission about this service between inspections. What the service does well: The service users live in a comfortable family style house supported by a consistent staff team who are well known to them and are able to identify and respond to their changing needs. A health care professional said ‘There is always a good atmosphere in the home, and residents and staff seem very happy’. Staff are very pro-active in monitoring the psychological and physical health needs of the service users. Health care professionals in contact with 30 Manor Road comment on the good standards of support service users receive from staff and the relaxed informal atmosphere. A relative commented that ‘The standard of care by the staff and all the support given by Mencap is beyond belief, 100 ’. They went on to say that services users ‘are treated as one big family,wonderful’. Service users lead busy fulfilled lives. Staff work to develop and maintain the independence, strengths, skills and self-esteem of service users through planned activities, contact with family and friends, access into the community and involvement in day-to-day daily living activities. Service users meet new staff as they are applying for jobs, which means that their views are considered as part of the recruitment process. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 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 Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 (YA) & 3(OP) – Standard 6 does not apply to this service. Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Detailed assessments are carried out before new service users come to live at 30 Manor Road to ensure that their needs can be met and they have had the opportunity to spend time in the home. Each service user has a tenancy agreement and details of the terms and conditions of their occupancy. EVIDENCE: The following comments were recorded by staff who supported the service users to respond to the Commissions questionnaire – Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 9 ‘I visited a few times sometimes with my family’. ‘I came to visit the home before I came quite a few times’. ‘I stayed overnight and met all the staff and people before I came here’. Copies of individual tenancy agreements and the terms and conditions of their stay at Manor Road were available and accessible to service users if they wished to see them. The care records of the newest service user provided clear evidence of the detailed assessment process that takes place to ensure their needs can be met. This included information from other health & social care professionals. The service user confirmed they had visited to see if they liked 30 Manor Road. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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 & 11 (OP) - 6, 9, 16, 18, 19 & 20 (YA) Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Service users have a detailed plan of care, which they are involved in developing and reviewing. The focus is on developing and maintaining independence and life skills supported where required by risk assessments to ensure the safety of service users. The current service users require support from staff to manage their medication. Overall the systems for ordering, administering and disposing of medication were found to be satisfactory, but some improvements are required to ensure service user safety. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 11 As the service users become older their health needs have changed and these have been responded to by referral to a range of health care professionals and identifying the wishes of service users and their families. Service users are supported by staff to maintain their privacy and dignity. They are able to make choices about who provides their personal care. The ethos of the management and staff group ensures resident’s rights are protected and they are treated with respect. EVIDENCE: Generally the medication systems were satisfactory. However there was no procedure available to inform staff of the specific actions they should take at each stage in relation to the systems in place at 30 Manor Road. Therefore standard 9 was not fully met and a requirement has been made. A review of storage arrangements should also be carried out with the pharmacist to ensure the humidity and temperature of the laundry does not affect the medicines. The outcome of this review and any risk assessments put in place should be recorded to demonstrate what action has been taken to ensure medicines are stored within their product licence. Staff receive medication training and their competency is assessed and recorded before they can give out medication. A system of regular reviews has been introduced. Together with their key worker, service users are being involved in developing person centred care plans to ensure that what is important to the service user forms the basis of the support they receive. Where appropriate people who are important to the service users are included. All service users had been supported to achieve high standards of personal care and express their individuality and preferences through clothing styles and accessories. An individual said their relative ‘ always looks well and is clean and well dressed. A community nurse in contact with the home said ‘health and social care needs are addressed, and the level of care provided is to a very high standard’. All 3 GP’s who responded to the Commissions questionnaire confirmed they were satisfied with overall care provided, that staff communicated clearly and worked in partnership with them, managed medication appropriately and demonstrated a clear understanding of the care needs of service users. The records examined provided very clear evidence of a proactive response to changes in health and ensuring that service users have access to available health screening. The psychological well being of service user is also kept under review. In response to a previous recommendation the manager has contacted families to identify their wishes in the event of the death of a service user and this is now recorded on file. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 12 The care records provided a clear picture of the actions required by staff to support service users. Where risks had been identified these were supported by risk assessments and additional information and training for service users to maintain their safety. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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 (OP) - 12, 13, 15 & 17 (YA) Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Each service user has an individual activity plan, which reflects their interests. Staff support service users make choices about what they want to do and maintain contact with family and friends. Service users are involved in preparing their meals and with the support of the community dietetic department staff make sure that a balanced diet is provided. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 14 EVIDENCE: Service users are able to access a range of activities which reflect their preferences. One person has a bus pass and following initial support from staff is now able to use local buses to visit friends and family. Another person goes swimming. Arrangements are made for service users to have holidays and specific interests such as train journeys are included. As well as attending a day centre at various times service users have days at home which enables them to relax, access local shops and services. Service users had recently been for a pub lunch and the day before the inspection had been to Southend. Judging by the comments and pictures of rides on the log flume this was greatly enjoyed. One member of staff is involving a service user in growing melons, tomatoes and cucumbers in the greenhouse. As well as recording individual interests and choices made by service users in the care records the service user meetings also provide information on the decisions being made in relation to social events. A relative commented that there were lots of outings and parties. The Community Dietician is involved in reviewing the menu plan and regularly assessing the nutritional needs of the service users. The dietician confirmed staff were monitoring the complex dietary needs of service users well. Staff demonstrated they had a good understanding of providing a well balanced diet and creating a relaxed sociable atmosphere at meal times. There were plenty of drinks, snacks and fresh fruit and vegetables available. Specialist utensils and cups are available to assist service users. Service users confirmed they enjoyed their meals and were able to make choices. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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 (OP) & 22 & 23 (YA) Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. There is an open and mutually respectful atmosphere in which service users and staff can raise issues and concerns. Service users are protected by the vigilance and knowledge of staff who understand their vulnerability in specific situations. EVIDENCE: No concerns have been raised with the Commission about this service between inspections. Service users are provided with support and advice regarding protecting their own safety when out and about in the community. The feelings of service users about situations in their lives are recorded and action taken to monitor and address issues that arise. Staff receive appropriate training in protecting service users and are aware of their responsibilities to report concerns under the Whistleblowing procedure. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 16 The residents spoke of their good relationships with staff, naming individuals they would go to with problems. Staff confirmed there was an open atmosphere within the home and management and staff group, which enabled concerns to be raised and addressed in a positive manner. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 & 26 (OP) - 24 & 30 (YA) Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Service users are living in a comfortable family style home in a quiet residential area, which provides good access to local shops and services. The home is comfortably maintained and a good standard of cleanliness was observed. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 18 EVIDENCE: Two service users showed the inspector their rooms, personal possessions and pictures, which were important to them. A ramp and handrails provide service users with independent access to the garden from the side of the house. Plans to provide a walk in shower and redecorate specific areas of the home have been agreed between Mencap and the landlord of the property. Lack of storage continues to be an issue. To protect service users window restrictors are provided on the first floor. There are no low surface temperature radiators. This has been risked assessed but there are now indications that for some residents, particularly one person who has been found sitting on the floor at night, that the risk may have increased. Some of the radiators are beside the beds. It is recommended that the risk assessments are reviewed and specific details of what is a safe surface temperature and how this will be achieved and monitored included. Where an increased risk is identified and as part of the on-going plan of refurbishment for the home low surface temperature radiators or radiator covers should be considered. The deputy manager has attended training to be a link between the home and Community Infection Control service so that information and updates can be made available to staff. There are procedures in place and equipment for staff to prevent cross infection. The deputy manager agreed to obtain a copy of the new Department of Health Guidelines – Infection Control for Care Homes (June 2006) Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 (OP) - 32, 34 & 35 (YA) Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. A consistent and experienced team of staff provide the support required by the service users to maintain satisfying and fulfilling lives. The recruitment procedures ensure services users are protected by employing suitable staff. EVIDENCE: A relative stated that the staff are ‘considerate and friendly’. During the day service users are supported by 2 staff and the manager. One person does a sleep in shift at night, which meets the current needs of service users. The home has access to Mencap relief support workers to supplement the staff team if required. The aim is to have staff who are known to the service users. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 20 Two staff have joined the team in the last year. Their records provided evidence that the required checks are carried out to ensure suitable staff are employed. Two references including one from the last employer and Criminal Record Bureau checks are obtained. As part of the interview process candidates spend time in the home and this gives service users the opportunity to be part of the recruitment process. It was not clear from discussions with the manager what action is taken by Mencap to advise new staff of the protection offered by immunisation. The deputy manager agreed to review this. New staff receive induction training and there are training programmes in place covering statutory training and care practices. A particular focus of the staff team has been the development of a person centred planning approach to express the views and aspirations of service users. Out of a permanent staff team of seven 2 staff and the manager have NVQ qualifications. One person is nearing to completing the course and 2 are about to start. All staff who were present on the day of inspection (5) feel there is a good staff team who work cooperatively in the interests of the service users. There are regular staff meetings and individual supervision sessions which provide the opportunity to reflect on working practices and training needs. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) 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, 33 35 & 38 (OP) - 37, 39 & 42 (YA) Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Service users are supported by an experienced and suitably qualified manager. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 22 Mencap has systems in place for monitoring and developing the quality of the service provided. This includes regular visits to the home by senior managers. There are systems in place to enable service users to have access to their finances and ensure transactions are monitored. Senior managers check the records when they visit the home. Mencap has systems in place to ensure that staff receive the required statutory training and that safety and servicing checks are carried out to protect service users and residents. EVIDENCE: The manager has been in post since 2002 and achieved the Registered Manager Award in February 2006. He is also involved in developing projects within Mencap demonstrating an on-going commitment to ensuring the service provided is in line with current professional practice. The systems for supporting service users to manage their finances appeared to be in order from the records seen. There are clear instructions for staff on their contribution to meals and social occasions when they go out with service users. Mencap has systems in place for monitoring the quality of the service provided. The records seen include action plans and timescales for any identified issues. Reports of the monthly unannounced visits to the home by representatives of Mencap under Regulation 26 are available to the manager and the Commission. The statutory training records confirm staff receive training and regular updates in the required areas including first aid, fire and moving & handling. In discussions with the manager it was suggested that the risk assessments required under the Health & Safety at Work Act are reviewed to ensure they meet the current standards required by the Environmental Health department. Accident and fire records are maintained as required. No issues were identified. The landlord’s gas safety check was carried out on 17.3.06 and the fire safety systems serviced on 21.3.06. Manor Road (30) DS0000019455.V305432.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 x 2 3 3 3 4 x 5 x 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 ENVIRONMENT Standard No Score 19 3 20 x 21 x 22 x 23 x 24 x 25 x 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 3 34 x 35 3 36 x 37 x 38 3 Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 YA20 Regulation 13(3) Requirement Put a medicines procedure in place and review the storage arrangements to ensure medicines are stored at the correct temperature. A copy of the Royal Pharmaceutical guidance – ‘The Administration and Control of Medicines in Care Homes and Children’s services’ should be obtained. Timescale for action 29/09/06 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 OP19 YA24 Good Practice Recommendations Review radiator risk assessments and include details of what a safe surface temperature should be, how it is achieved and monitored. Consider providing low surface temperature radiators or covers in high risk areas as part of any planned refurbishment. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Manor Road (30) DS0000019455.V305432.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!