Inspection on 11/01/07 for Mansfield Manor Care Home

This inspection was carried out on 11th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Mansfield Manor Care Home 28/11/05

Mansfield Manor Care Home 17/06/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Mansfield Manor Care Home 30-32 Chesterfield Road South Mansfield Nottinghamshire NG19 7AD Lead Inspector Jayne Hilton Unannounced Inspection 11th January 2007 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 Mansfield Manor Care Home DS0000062255.V323917.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. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mansfield Manor Care Home Address 30-32 Chesterfield Road South Mansfield Nottinghamshire NG19 7AD 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) 01623 631163 01623 631163 info@mansfieldmanor.co.uk Sherwood Healthcare Limited Cheryl Brown Care Home 38 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (30) of places Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within categories OP (30) or DE (8) within a total registration of 38 beds. 28th November 2005 Date of last inspection Brief Description of the Service: Mansfield Manor is a purpose built care home close to Mansfield town centre. The entrance is accessible for wheelchairs. The home is registered for Nursing, and residential care. A service is also offered for older people with needs relating to Dementia. Accommodation is provided on three floors, accessible with a passenger lift, and all bedrooms have en-suite toilet and washbasin facilities. Two double rooms are provided for couples who choose to share, but all other rooms are single. There are spacious communal areas and seating areas are also provided outside in a very pleasant garden area. Information was provided by the acting manager on 11-1-07 on the range of fees charged; these are between £283-£351 service users pay extra for newspapers, hairdressing and chiropody. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 6 daytime hours. The main method of inspection used was called ‘case tracking.’ This involved selecting four residents and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents’ records and documents. The residents who were “case tracked” were not able to help by giving an opinion about the care provided. Comments from one relative only were obtained. Three members of staff, the manager and the Registered Provider were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. What the service does well: Service users needs are assessed and they can be confident that their needs will be met. Trial visits are arranged and contracts provided. Service users are afforded appropriate respect and dignity at the home and have their personal and health care needs met. 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. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 6 Service users are helped to exercise choice and control over their lives and maintain contact with family friends/representatives and local community as they wish. Service users receive a wholesome appealing balanced diet in pleasing surroundings. Mansfield Manor provides a safe, clean and well-maintained environment for service users. Staffing levels at the home are appropriate in meeting the needs of the service users. Competent, trained and supervised staff supports Service users. Recruitment practices are satisfactory. The manager at Mansfield Manor is professional, fit to be in charge, of good character and is able to discharge her responsibilities fully. The home is run in the best interests of the service users and service users financial interests and their health and safety are safeguarded. Service users know how to make a complaint and feel confident that they are listened to and feel safe. What has improved since the last inspection? The manager has improved the process for assessment and admission for service users and the system used for care planning ha also been further developed and improved. Service users now have more choices on the menus and staff are trained in abuse awareness and ongoing refreshers in the topic. The arrangements in place for staff supervision has been improved and updated checks are in place for legionella. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 8 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 Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed and they can be confident that their needs will be met. Trial visits are arranged and contracts provided. The home does not provide an intermediate care service. EVIDENCE: A comprehensive assessment document is used pre- admission and upon admission to the home, with separate assessments devised for service users with dementia type or nursing needs to obtain more detail about the individuals specific needs. Equality and diversity needs are identified within the documentation and staff members receive training from the registered provider in Equality and Diversity. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 10 Four service user’s assessment documents were examined and all were found to be well written with care plans devised from their identified needs. Attention is required however to ensure dates and signatures are completed. The new assessment documentation contains a section for service users/representatives to sign that they have received a copy of the Service Users Guide. Contacts were viewed and extended community care assessments and contracts apart from one person placed from out of County, which the manager reported was with the provider currently. This document should be made available for the next inspection. The manager explained that she visits potential residents in their current environment and trial stays are arranged wherever possible and within funding availability. A service user confirmed that she received a brochure about the home on before admission and had trial visit and enjoyed a meal during that time. A copy of the report from the previous inspection was displayed in the manager’s office. It was discussed that information to inform service users/representatives of how to access inspection reports including internet access should be displayed near the visitors book and on the service users notice boards and mentioned in the newsletter. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are afforded appropriate respect and dignity at the home and have their personal and health care needs met. The system in place for the management of medication needs some improvement to ensure service users are fully protected. EVIDENCE: Four care plans were examined and were detailed and up to date and contained comprehensive risk assessments and nutritional screening. Service users or their representatives are invited to be involved within the care planning process, including reviews of these and a staff member has delegated responsibility to see relatives when they visit and gain a signature when they have reviewed the care plan. Good daily records were in place and included reports of dietary intake of service users. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 12 Service users health needs were well addressed and professional visitors recorded for such as chiropody treatments and GP visits. Attention should be given to ensure that when blood tests are taken that the reason for the blood test is documented and a record made of the results/follow up actions. Life History profiles are used, which provide staff with holistic information about service users interests and previous lifestyle. Privacy and dignity issues are covered within information to staff within the care plans. It is recommended that a care plan be implemented with a seizure monitoring record sheet for the service user identified with suspected seizures. Both management and staff at Mansfield Manor demonstrated a thorough knowledge of the principles of maintaining privacy, dignity and respect. Service users spoken with were very complimentary about the way staff addressed service users and stated that all the staff within the home are lovely, helpful and caring. It was evident that staff always knocked on the resident’s bedroom door before entering. Service user spoken with also stated that the staff respected their privacy and dignity when bathing or performing personal care. It was evident that service users receive appropriate assistance from care staff at the home to maintain a pride in their appearance; all service users were dressed in appropriate clothing for the season and were very presentable. It was observed that male residents were not always clean-shaven and one service user’s fingernails were long and needed cutting. It is recommended that staff address this and personal care charts are implemented alongside care plans which detail service user preferences for shaving routines. The Registered Provider and Registered Manager now audit the care plans and where shortfalls are identified the staff member is spoken to about addressing this. A service user commented that staff always help and attend to promptly when needed. A service user who had her care needs met in bed had appropriate care charts in place, appeared comfortable and well cared for. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 13 The inspector witnessed care staff interacting with the service users in a very pleasant and respectful manner and it was evident that the service users were very comfortable and contented within the home environment. A relative commented that privacy and dignity is most definitely respected and that her mum seems happy and the entire family feel, she looks better. The system for the management of medication and clinic room was assessed and was generally satisfactory with regard to ordering, receipt and disposal, storage, policies and procedures and emergency equipments and cleanliness and hygiene. Observation of staff practices identified that the medication administration records [MAR] were not always being checked prior to dispensing to check the correct prescription and dosage and there was evidence on the medication administration records that confusion had occurred with one, service users changed dosage. The entry on the MAR was handwritten with no signature at all and should also have been witnessed by a second qualified member of staff. The temperature of the room where medication is stored is not being monitored and this is recommended. A requirement is set to ensure medication management ensures service users safety. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 13-15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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 are helped to exercise choice and control over their lives and maintain contact with family friends/representatives and local community as they wish. Service users receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: It was established that Mansfield Manor employs an activities coordinator three days a week in an attempt to provide service users with stimulating social activities such as bingo, dominoes, cards and movement to music. Guest entertainers also visit the home to provide entertainment for service users enjoyment. Social activities provision within the home on the day of the inspection was a Quiz and Tuesdays music to movement /ball games. Outings and entertainers, parties, pantomime trips are provided in addition to this. A group of service users, staff and relatives went to Skegness in the summer and boat trips in summer and pub meals are favourites. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 15 The Mansfield Manor newsletter provides information on social events such as a family, mince pies and sherry afternoon and a Christmas party. Service users spoken with stated that they had enjoyed a belated Christmas party held the week prior to the inspection. A resident relatives committee are instrumental in the provision of events and activities also and have links with community contacts, local church etc. A relative commented about activities as follows: “ Lots going on mum doesn’t join in they do try to get her involved and she is going to pantomime. My sister came to the party before Christmas”. In Discussion about access to family and friends and social interactions a relative confirmed that they visit when convenient to their lifestyles and are always made to feel welcome. Service users stated that the food in the home is very good and wholesome. The lunch being served at the time of the inspection appeared, wholesome, and appetising. The daily menu was available for inspection and now provides two meal choices available at the lunchtime period. The menu could be further improved by offering a vegetarian option rather than two meat options or as an additional one. Breakfast options include cereals, porridge or cooked breakfasts and toast. The lunchtime observed was relaxed and unhurried. Staff were observed assisting service users appropriately. Record keeping of choices made by individuals was not consistent and needs to be undertaken daily. A service user commented that the meals were very nice and that there were lots of choices. A relative added “ The quality of food is good and the dining area pleasant, when I visited at team time I thought the chicken sandwiches were really good, plenty of meat, there are various sandwiches on offer, mum has a choice and has put weight on, as she did have an eating problem before she moved into the home”. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users know how to make a complaint and feel confident that they are listened to and feel safe. EVIDENCE: Service users within the home and in the completed questionnaire all stated that they felt safe and protected. The manager of the home stated that new recruits to the home are encouraged to read documentation appertaining to the protection of the vulnerable adult. It was evident that staff spoken with are aware of procedures to be followed in relation to the reporting of suspected abuse and were aware of appropriate actions to be taken if they suspected abuse was happening within the home setting and have undertaken training in abuse awareness. There have been no Adult Protection issues in the home since the previous inspection. In ensuring that any concerns are addressed effectively at the home the manager utilises a questionnaire to establish the service users satisfaction with the facilities available at the home. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 17 The questionnaire is available in the reception area and once filled out, either by the service users or their representatives, the form will be passed to the manager. It was established that the manager of the home would attempt to address any issues of concern that the service user or their representative might have. The complaints procedure is contained within the Service User Guide, which is issued to all service users and was observed in the bedrooms viewed. Another copy of the procedure is on the notice board in the reception area. Relatives spoken with said they know how to make their concerns known and would speak to the manager or owner and felt the complaints would be taken seriously. Records of complaints were seen during the inspection. A total of seven complaints were documented over a period eighteen months, two were substantiated, and five partly substantiated. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mansfield Manor provides a safe, clean and well-maintained environment for service users. EVIDENCE: It was evidenced that the home is maintained to a satisfactory standard throughout, however the bathrooms and shower room are looking tired and the Registered Provider reported that these are to be refurbished imminently. The handyman was measuring for tiles on the day of the inspection. It was also evidenced that external contractors perform appropriate maintenance schedule on all equipment designed of aid mobility such as wheelchairs, hoists and specialist baths. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 19 A check on the servicing records evidenced that these were mostly up to date, however the five yearly electrical circuit test certificate and annual gas safety certificate was overdue and these needs addressing promptly. A fire risk assessment was seen to be in place. One bathroom had equipment stored within it and the manager said the bath was not used however the toilet in there was accessible so the manager was advised to make a decision as to what its purpose and lock off if used as storeroom as all service users had accessible toilets in en-suites in the rooms close by. Gloves, paper towels and liquid soaps were provided throughout the home and the home was clean and smelled fresh. A relative commented that this is how she finds the home when she visits, she said her mums room was spotless and always smelled fresh and always clean bedding provided. The kitchen was observed to be clean and washing up liquid and antibacterial spray was clearly available for use by kitchen staff. Food Safety practices were satisfactory. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are appropriate in meeting the needs of the service users. Competent, trained and supervised staff supports Service users. Recruitment practices are satisfactory but keener vigilance on references would ensure the systems in place are robust. EVIDENCE: The manager provided a copy of the staffing rota with the pre-inspection information, which evidenced that staffing levels are appropriate to meet service users needs. On the morning of the inspection 5 carers, and one qualified nurse was on duty, throughout the afternoon period three carers, and one qualified member of staff was on duty and the night period was covered by two carers and one qualified nurse. It was established that the manager of the home is employed on a supernumerary basis so she can manager the home effectively. Staff files contained appropriate information in relation to Criminal Records Bureau (CRB) checks and two satisfactory references. The identity of staff Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 21 employed at the home could be established through appropriate documentation such as passports, birth certificate or bank statements. It was established that no new members of staff commence employment until the aforementioned documentation is in place and references are satisfactory. One reference was questioned by, the inspector, as this had been provided by a different person than that given on the application details. The manager was requested to ensure its validity and inform the inspector of the outcome and to be more vigilant in future recruitment of staff. Training records evidenced a good level of training. The inspection process allowed the informal discussion with a member of the care staff employed at Mansfield Manor. It was established that she had received in house training in, induction, infection control, moving and handing, dementia care, health and Safety, fire prevention, first aid, food and hygiene, the safe handling on medicines and abuse awareness. Records also evidenced that 50 of care staff have achieved NVQ at level 2. The manager ensures that staff members receive supervision from either herself or the new owner of the home in an attempt to identify and promote good care practice at the home. New documentation was in place to record supervision sessions with staff. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager at Mansfield Manor is professional, fit to be in charge, of good character and is able to discharge her responsibilities fully. The home is run in the best interests of the service users and service users financial interests and their health and safety are safeguarded. EVIDENCE: The manager of Mansfield Manor attained her Registered General Nursing qualification in 1977. Since that time she has gained considerable experience in both the primary and secondary care settings. Having registering with the Commission for Social Care Inspection as the registered manager of the home Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 23 last year, she is currently in the process of undertaking the degree level Registered Managers Award. In the absence of a manager the day to day running of the unit is performed by qualified nursing staff, it was established that the manager is also on call should any concerns arise in her absence. It was evident that the manager promotes a friendly relaxed environment for the enjoyment of the service users and service users spoken with felt confident in the acting manager’s ability to manage the home in a clear supportive manner. It was established that a residents and relatives meetings are performed on a three monthly basis so as to identify and address any areas of concern in relation to the care afforded to service users within the home. A summery of the meetings are available on the monthly newsletter produced at the home. The Registered Provider has started a Quality Monitoring system to supplement the service user and relative surveys carried out and the auditing processes already in place. The Registered Provider visits the home several times a week and evidence of Regulation 26 reports have been sent to the Commission for Social Care Inspection. At the time of the inspection it was evidenced that the service users monies are effectively managed. A clear record of monitory transactions could be evidenced. The case tracked service users, monies are securely stored, in individual plastic folders and stored within a secure environment. Receipts are evident for all transactions performed, and a clear financial audit trail was evident thus protecting the service users from financial abuse. As stated previously in the report staff members receive formal supervision as required to meet regulation. Record keeping was satisfactory and service users information is stored securely. The information supplied by the manager within the pre inspection questionnaire for health and safety checks and audits was random sampled and found to be correct. Policies are in place for the management of Health and Safety and staff are trained appropriately in health and Safety subjects. There were no issues identified in relation to the environment or unsafe practices on the day of the inspection. The manager could also demonstrate that bed rail checks are performed on a monthly basis, hot water outlet checks are performed on a monthly basis and window restrictor checks are also performed on a monthly basis together with the staff call system. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 24 Outside contractors are employed to chlorinate water systems to inhibit the formation of Legionella contamination. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 25 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 3 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 4 X 3 4 4 4 Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 Regulation 13 Timescale for action The registered person shall make 11/03/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Requirement 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 Refer to Standard OP3 OP3 OP8 OP8 OP8 OP19 Good Practice Recommendations Ensure dates and signatures are completed on service users documentation. Include signatures for issue of bedroom door keys and for lockable facilities or ensure appropriate risk assessments are in place. Ensure a care plan and monitoring sheet is implemented for suspected seizures for the service users identified. Ensure blood tests are fully recorded and followed up. Implement personal care charts for shaving routines and nail care. Ensure the shower room and bathrooms are refurbished as planned. DS0000062255.V323917.R01.S.doc Version 5.2 Page 27 Mansfield Manor Care Home 7 8 OP19 OP29 Ensure the electric circuit and gas safety certificates are renewed. Be more vigilant in checking staff references for validityinform the inspector of the outcome of the check carried out. Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mansfield Manor Care Home DS0000062255.V323917.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!