Inspection on 05/06/06 for Manorbrooke

This inspection was carried out on 5th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Manorbrooke 27/08/08

Manorbrooke 27/08/07

Manorbrooke 17/01/06

Manorbrooke 15/08/05

Manorbrooke 15/09/04

Manorbrooke 22/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Manorbrooke Bevis Close Stone Dartford Kent DA2 6HB Lead Inspector Elizabeth Baker Key Unannounced Inspection 5th June 2006 10:30 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 Manorbrooke DS0000037766.V294527.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. Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manorbrooke Address Bevis Close Stone Dartford Kent DA2 6HB 01322 223628 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) patricia.isted@kent.gov.uk Kent County Council Mrs Patricia Joanne Isted Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Manorbrooke is a care home providing personal care for 33 Older People. Kent County Council (KCC) is the registered provider. Manorbrooke was opened in the 1960s as a purpose built local authority home. All bedrooms are for single occupancy, with 19 rooms situated on the ground floor. Nine bedrooms have ensuite facilities. All bedrooms are connected to the call bell system and have a television point. None of the bedrooms have a telephone point. There is a passenger lift to all rooms on the first floor. The home is divided into three units. The first floor unit has a large/dining room. The two units on the ground floor have their own day lounge, but share a large dining room. The home is situated in Stone, off the main road between Dartford and Gravesend. Buses, shops, post office, church and pubs are within easy walking distance for able-bodied residents. Gravesend and Dartford are about 5 and 2 miles away respectively. Darent Park Hospital and the Bluewater Shopping Centre are nearby as is access to the main A2/M25 interjunction. The maximum current fee payable is £351.91, with additional charges for newspapers, toiletries, hairdressing, chiropody, dentists and opticians. The latest Inspection Report is publicly displayed in the main reception. Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first unannounced visit to the home for the inspection period 2006/07. The inspection took over seven hours and was carried out by lead inspector Elizabeth Baker. The visited consisted of a partial tour of the premises, inspecting some records for case tracking purposes and talking with some residents and staff. A number of residents and staff were spoken with in private. The manager Mrs T Isted, assisted throughout the visit. The main purpose of the visit was to check the Provider’s compliance against the requirements made at the last visit to the home on 17 January 2006. Some judgements about the quality of care, life and choices were taken from conversations with residents and staff, as well as direct and indirect observations. Some care records were seen as part of case tracking. In support of this visit the Commission received comment cards about the service from six residents, nine relatives/visitors, one GP and four care managers. At the Commission’s request the provider completed and returned a pre inspection questionnaire. Some of the information gathered from these sources has been incorporated into the report, including quotations. At the time of the visit 33 residents requiring personal care were residing at the home. What the service does well: A quiet and calm atmosphere was noticeable around the home. Good interaction was seen between staff and residents. Comment card responses from residents and relatives/visitors and care managers included “I have been very pleased with [resident’s] treatment and care”; “We are very pleased with the attitude of staff and the overall care...” “In my opinion Manorbrook is one of the best run local services we have in Dartford. The management and staff are pleasant and very helpful with queries or information”; [I] am happy with the care I get here and enjoy the company of other residents”; “All the care I get here I am very happy about and satisfied”; “Staff always seem to be on the ball when I need them” and “I think the meals here are very good. We are always offered a choice everyday and it is very nice to have a variety of meals”. The manager endeavours to ensure that prospective and current residents are provided with lots of up to date information about the home. Good arrangements are in place to reduce any anxieties prospective residents may have when moving into the home. Manorbrooke DS0000037766.V294527.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. Manorbrooke DS0000037766.V294527.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 Manorbrooke DS0000037766.V294527.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s Welcome Pack provides current and prospective residents and their advocates with all the information they need to make a decision about moving into the home. EVIDENCE: The home has just reviewed and updated its Welcome Pack, which contains the service user guide, statement of purpose, terms and conditions of occupancy and other relevant information. To supplement this a leaflet has been composed which summarizes some of the information in the Welcome Pack. Copies of the Welcome Pack are made available to both prospective residents and current residents. Indeed the Welcome Pack was seen in bedrooms visited. Prospective residents are invited to visit the home with their families and or advocates prior to deciding whether to be admitted. Where such a visit is not possible, a senior team leader and health care assistant visit the prospective resident in their current environment. The home endeavours to ensure the visiting staff are the same staff that welcome the new resident on arrival at the home, thus minimising any anxieties the new resident may have. Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 9 The majority of residents admitted into Manorbrook are assessed through care management. Care management supply the home with a comprehensive assessment of their client’s needs. For self-funding residents, the home has devised its own pre admission assessment. These assessments are used as the basis to devise the residents’ care plans. The home is registered for personal care only. Where a resident’s condition changes, action is taken to arrange a re-assessment of the resident’s needs. This may result in the resident being transferred to another type of care home, such as one providing nursing care. A resident described their experience of coming to the home for a trial period before deciding whether to stay on a permanent basis. The resident remarked that they were glad they had made the decision to stay. The home is not registered for intermediate care. Standard 6 is not applicable. Manorbrooke DS0000037766.V294527.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The maintenance of care records continues to improve but residents are still at risk because of shortfalls. Personal care is normally offered in a way to protect residents’ privacy and dignity. EVIDENCE: Four care records were inspected as part of case tracking. Care records contained care plans, some risk assessments and body maps. The residents had signed care plans inspected. Although it was evident that care staff are striving to improve their record keeping skills, some records were incomplete of pertinent information. For example a resident said they occasionally experience pain and take painkillers for this. The care record did not record this. The records indicated the resident had been treated by a health care professional and special bandages had been applied. The resident was not wearing these at the time of the inspection. The records did not record the bandages were no longer necessary. A visit to the resident’s room identified two tubes of prescribed emoluments and an empty box of prescribed corticosteroids cream. The resident’s medication administration chart did not include these preparations. It was also noted that a daily record entry for the Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 11 23 May 2006 referred to a request for the corticosteroid cream to be reordered. Staff were unable to identify whether it had in fact been re-ordered and if so had been received. The resident said they had mislaid their glasses. The care records recorded the resident required them. The records did not record the glasses had been lost. The manager was unaware of this also. Appropriate support had been obtained from a health care professional for a resident identified as nutritionally at risk. However the model of care plan used does not promote full instructions to be inserted if the resident’s assessed needs require this level of detail. Therefore the resident’s care plan had not been completed to reflect the clinician’s instructions. There was no separate nutritional assessment for this resident either. The resident was being weighed regularly. The clinician’s separate notes were included in the care records. Another resident indicated during the inspection that they had a special mattress on their bed to make them more comfortable. However details of this overlay mattress had not been included in the resident’s records. It was also noted that not all residents are provided with continence assessments where there is an assessed need. Care records contained moving and handling assessments. However they do not include references to pain sites, where there is a known pain problem. Having this information prevents staff inadvertently causing additional discomfort when providing assistance. Records are kept of daily and night entries. However it was noted on this visit that daily entries are not always made. The importance of staff recording brief but meaningful details of any support, assistance, observation, intervention and quality of day experiences of residents on a daily basis was discussed. Records are evidence of all care needed and provided and would be required for scrutiny if an investigation into a care issue had to be carried out. Since the last inspection the dispensing pharmacy has ceased using correction fluid on medication administration record charts supplied to the home. However the type of charts supplied continue to state administration times as morning, noon, tea and bed. Medications are supplied in blister packs. The manager said where medicines require to be administered at a specified time they are kept and administered separately. However a review of one blister pack identified that it contained a once a week medication, which is required to be taken 30 to 60 minutes before food and other medications. Although the dispensing label indicated the medication must be taken before food it did not indicate it must not be taken before other medicines. The resident was noted to be receiving other medicines. This situation may prevent medicines not being as effective as intended by the prescriber and manufacturer. Both medical rooms were clean and tidy on this visit. The manager said since the last inspection appropriate locks have been fitted on the medical room Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 12 doors and one of the CD cupboards has been replaced. Hard back record books are now available in both medical rooms to record the administration of controlled drugs, when applicable. Residents said staff assist them with their personal hygiene needs in a dignified manner. Residents also said they can have baths as often and at the time they prefer. However one health care assistant was seen entering a toilet to provide assistance to a resident without knocking and proceeded to provide the assistance with the door left open. The resident was in a state of undress. Since the last inspection the manager has written to advocates to obtain details of residents’ wishes and preferences in respect of death and dying. This should ensure that the home is aware of the arrangements to be made at a sensitive time without adding to relatives and advocates distress. Manorbrooke DS0000037766.V294527.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy living at this home because it generally matches their expectations and satisfies their social, religious and recreational interests and needs. EVIDENCE: Care records inspected contained brief biographical details and social care plans. A knitting group session was in progress at the time of the visit and residents commented on how much they enjoy these sessions. Another resident was knitting in another lounge and said she enjoys knitting but prefers to do it on her own. Residents said they enjoy the exercise sessions, which have just been introduced and one resident described the trip to Bluewater, which they really enjoyed. Residents said religious services are held monthly and another resident said they are visited by a layperson from their church. An activities diary for 2006/07 has been produced and covers activities including baking sessions, afternoon film shows, games, exercises, art classes and bingo. Despite this provision a comment card respondent added “I feel that more should be done to stimulate the residents both physically and mentally, as they seem to spend a lot of time sitting in chairs doing nothing. I think some kind off occupational thererapy would be beneficial. Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 14 The home does not currently employ a permanent activities co-ordinator. However the manager said following some staff changes, it is proposed that a dedicated 20-hour week post will be made available. Residents described their going to bed and getting up routines, with some residents preferring not to retire until after 10pm. This is good practice as it shows the home is operating for the residents. Residents are provided with early morning tea in bed if this is their wish. Visitors were seen coming and going throughout the visit. The home has two quiet rooms in which residents and their visitors can meet for private conversation or contemplative purposes. Various information leaflets, including advocacy contacts, are contained in a rack in the main reception, for residents’ information. An appetising meal was seen served during the visit. Residents said meals are good and drinks are available when they want them. Residents also spoke about the glass of sherry, which they can have with their Sunday lunch. The manager said a new theme night meal has been introduced. It is intended this will be done on a monthly basis. The manager reported that so far it has been successful. However these meals are in addition to the normal supper menus, as it is recognised that not all residents like to eat Chinese or Italian food. As stated previously, specialist advice is sought from appropriate health care clinicians when residents’ nutritional needs require this. The home had been decorated to reflect the forthcoming World Cup Football and some residents said they were looking forward to the matches. All the returned comment cards from residents indicated they always like their meals. Manorbrooke DS0000037766.V294527.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with some residents feeling their views are listened to and acted on. EVIDENCE: Although the complaints log was not inspected, residents spoken with indicated they knew who to speak to if they had a complaint or concern. Residents said when this had happened; the matters had been resolved to their satisfaction. The Welcome Packs contain a separate leaflet on the home and provider’s complaint procedure. Other copies of this leaflet are kept in the information rack in the reception. However despite this two relatives/visitors respondents indicated they were not aware of the home’s complaint’s procedure. Details of how to contact the Commission are displayed in the reception and included in the Welcome Pack. All the returned comment cards from residents indicated they knew how to make a complaint. The returned pre inspection questionnaire indicates the home has received one complaint since the last visit. The complaint was substantiated. The form also indicates there have been no staff referrals under the Protection of Vulnerable Adults procedure. The Commission has not received any complaints about the home. The two members of staff interviewed said they had not received adult protection training either at this home or in their previous employments. Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 16 However both described appropriately what they would do if they had a suspicion of abuse. Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Continued improvements to the home’s environment will enhance residents’ quality of life and safety. EVIDENCE: Areas inspected were clean, tidy and odour free. All the comment cards returned from residents indicated the home is always fresh and clean. Since the last inspection a section of path around the home has been renewed with tarmac to allow residents to move safely around the home. The patio and grass areas were in a tidy state and the maintenance man was in the process of cutting back overgrown shrubbery and ivy, which had again began to impinge on the building. Some facia boards at the front of the home have been replaced, making the entrance more welcoming. However the tarmac drive still requires repair or re-surfacing, as the current situation poses potential trip hazards to both residents and visitors. Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 18 The manager said fifteen new chairs have been purchased and a bedroom redecorated since the last visit. The manager has devised a redecorating programme for the home. It is intended that one lounge will be redecorated as well as the corridors in a particular area. This is good news as the state of the corridors around the home is looking tired, with bits of wallpaper coming away and doorframes and doors contact damaged. The additional quiet lounge now situated on the first floor still requires redecoration. The room was previously a bedroom and although the sink has been removed plumbing pipes remain. Proper cleaning of the laundry and one sluice room is currently compromised because the flooring in the laundry has not been repaired and some surface tiles, which have been removed in the sluice room, cannot yet be replaced. The home was opened in 1960s and still retains some original fitments. This includes sluicing facilities, which despite the best efforts of staff to keep them clean are becoming lime-scale damaged, which makes it difficult to maintain to a hygienic standard. Details of the redecorating programme were included in the last residents’ committee meeting minutes. This is good practice and ensures residents are aware of and understand why they may experience some disruption to their normal routines. Corridors are wide and fitted with handrails. This assists residents in moving independently around the home. A loop system has been installed in all three lounges. This not only assists residents who have hearing problems, but also those residents who do not and no longer have to endure programmes being broadcast at high volumes. Bedrooms visited had been individualised with personal effects. Residents spoken with indicated they like their rooms. However a care manager indicated on their returned comment card that their client has a TV in their room that is too high to be turned on. Since the last inspection the manager has obtained quotes for re-surfacing the drive and replacing or renewing exterior soffits. However this work cannot commence until permission and resources are received from the service provider. Manorbrooke DS0000037766.V294527.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff morale is good resulting in an enthusiastic workforce that work positively with residents to improve their quality of life. EVIDENCE: As well as care staff, staff are employed for cooking, cleaning, administration and maintenance/gardening. Rotas demonstrate the home is staffed 24 hours a day, including two awake and one sleeping on duty at night. Residents spoken with said responses to alarm bells are generally good. A number of staff were seen sitting with residents having a general chat in a relaxed manner. Residents said they feel listened to. The turnover of care staff is low, which provides residents with continuity of care. The home is striving to achieve 50 of care staff are trained to NVQ level II care. To date 40 of care staff have attained this qualification. Recent training has included First Aid (1 and 4 day courses), foundation food hygiene, infection control, medicine administration and care planning. The home is about to introduce a training matrix, which will enhance the current system of identifying the training needs of all staff. The manager said District Nurses have offered to provide care staff with some training, and intend to start this with diabetes and catheter care. No new care staff have been employed at the home since the last inspection. Two files of newly appointed domestic staff were inspected. One member of Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 20 staff had been transferred to this home from another KCC home under TUPE arrangements. The transfer paperwork was in place. The other file identified that requisite forms, ID and references were in place. Both staff members described their recruitment experience, which included interviews, supplying documents to support their identification and their ongoing induction process. Manorbrooke DS0000037766.V294527.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 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 an improvement plan for the home, which she effectively communicates to residents and staff. However the manager is reliant on the service provider to ensure adequate resources are available to carry this out in greater detail. EVIDENCE: The manager has been in post for approximately six years. She has over 11 years management experience in care of the elderly and has completed the Registered Managers Award course. Residents and staff spoke openly about their experiences of living and working at the home. Meetings are held to obtain residents’ views on services and facilities provided at the home. A representative of the provider regularly visits the home to ensure it is operating in a satisfactory manner. Where Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 22 matters are identified during these visits as needing attention, the home is required to do this and the matter re-inspected at the next visit. The manager endeavours to meet requirements and recommendations made by the CSCI within specified timescales, where she has budget control. However where the requirement may incur greater costs, the manager is dependent on provider’s approval and authorisation before such work can be carried out. The latest copy of the inspection report is publicly displayed in the reception for information purposes. It was difficult to decipher some pertinent information from the care records of a newly admitted resident because of the poor quality of the forms. Following recommendations made at the last inspection, the administrator now provides monthly statements of accounts to residents and or their advocates if they require them. This system enables residents to have more control over their funds. When monies are received the name of the depositor is now recorded, as well as that of the resident to whom the deposit refers. This information should allow for easier auditing, especially if an allegation of misappropriation of funds was made. Records of residents’ monies are audited as part of the provider’s annual audit of the home. The administrator is also required to prepare and submit monthly returns to the provider, including details of transactions made on behalf of residents. A member of staff said they have received a “one to one” with their line manager and have been told to expect these sessions regularly. The staff member said they had been supplied with a copy of the meeting notes. The returned pre inspection questionnaire indicates servicing of the home’s equipment is carried regularly. Details of fire safety checks are kept. Although it was established that regular checks are carried out, it was difficult to ascertain this information without the manager’s assistance as details are now kept in two separate books and do not provide for a coherent picture. Because of time constraints, policies and procedures and accident book were not inspected on this occasion. Manorbrooke DS0000037766.V294527.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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 2 3 3 2 3 Manorbrooke DS0000037766.V294527.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. 2 3. Standard OP7 OP9 OP19 Regulation 15 13(2) 23(2)(b) Requirement Care plans must be complete of all current needs and support. Treatment emoluments must be applied as per the prescriber’s instructions. The driveway and remaining paths must be repaired or resurfaced. (Timescales 31/10/05 and 30/06/06 not met although quotations obtained) The home must be kept in a good decorative order both internally and externally. This refers to corridors and roof soffits. (Timescale 30/06/06 not expired, although quotations for soffits obtained). The laundry room must be made good to allow for effective cleaning. This refers to the flooring. (Timescale 30/06/06 not expired). All heating appliances in rooms used by residents must be protected. (Timescale 30/06/06 not expired – cover purchased DS0000037766.V294527.R01.S.doc Timescale for action 30/09/06 30/06/06 30/09/06 4. OP19 23(2)(d) 30/09/06 5. OP26 13(3) 30/09/06 6. OP25 13(4)(a) 30/06/06 Manorbrooke Version 5.2 Page 25 but not fitted). 7. OP34 25 The service provider must be make sufficient resources available to ensure the home is kept in a safe and good decorate state both internally and externally. 30/09/06 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 2 3 4 5 6 7 8 Refer to Standard OP7 OP8 OP8 OP9 OP10 OP18 OP28 OP37 Good Practice Recommendations Moving and handling assessments should contain details of pain, where this is assessed as a problem Continence assessments should be available for those residents assessed as requiring them. Daily statements should be recorded for all residents to reflect their condition and quality of day experiences. Medicines must be administered as per the instructions of the prescriber and manufacturer. Personal assistance to residents should be provided in a dignified manner All staff should receive adult protection training. Fifty percent of unqualified care workers must be trained to NVQ level II or equivalent by 31 December 2005. All records must be legible and coherent. Manorbrooke DS0000037766.V294527.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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