Inspection on 13/01/06 for Manson House

This inspection was carried out on 13th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Manson House 22/11/07

Manson House 26/02/07

Manson House 08/05/06

Manson House 21/10/05

Manson House 17/03/05

Manson House 13/01/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Manson House Manson House 111 Northgate Street Bury St Edmunds Suffolk IP33 1HP Lead Inspector Deborah Seddon Unannounced Inspection 13th January 2006 09:30 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 Manson House DS0000032883.V276717.R01.S.doc Version 5.1 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. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Manson House Address Manson House 111 Northgate Street Bury St Edmunds Suffolk IP33 1HP 01284 753106 01284 763553 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) The Royal Agricultural Benevolent Institution Mrs Delphine Yvonne Bonas Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 2005 Brief Description of the Service: Manson House is registered as a care home providing care and accommodation for a maximum of 24 older people. The Home is owned by the Royal Agricultural Benevolent Institution (RABI) and has been providing care and accommodation to older people from the farming and agricultural community for approximately 28 years. The Home operates a waiting list and welcomes applications from those with farming and agricultural backgrounds, however the waiting list is open to other people, from around the East Anglian region. The Home is located in the residential area of the market town of Bury St Edmunds and is a few minutes walk from the town centre, the Abbey Gardens, shops and amenities. The building spans three floors and is served by a shaft lift and two stair lifts. All bedrooms benefit from en-suite toilet facilities with one bedroom also having a bath en-suite and five other bedrooms having an en-suite shower. The Home also has an assisted bathroom on the ground floor, two assisted bathrooms on the first floor and a walk in shower on the second floor. In addition to the en-suite toilets, the home provides three other toilets. The bedrooms to the front of the house face the street, whilst the bedrooms to the rear have a pleasant outlook over the gardens, summerhouse, green house, seating and an aviary of Cockatiels, which were donated to Manson House. The RABI also own 19 sheltered flats, which are also, located in the grounds of Manson House. Service users have access to a range of communal rooms (lounge, library, hobbies room and summer house). The communal areas are comfortably furnished in keeping with the style and design of the building. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which started at 9.25am. It took place over four and half hours during a weekday. The inspection focused on looking at the standards not assessed at the last inspection of the 21st October 2005. Therefore to have a true reflection of the home this report should be read in conjunction with the report issued from the October inspection. Time was spent with the manager and administrator discussing how the home supports residents to manage their finances and the progress of the requirements from the previous inspection. A tour of the premises was made and a number of records were examined including those relating to residents, staff and policies and procedures. The inspector-spent time talking with three residents collectively and two individually and a member of staff. What the service does well: Manson House continues to provide residents with a welcoming home which has a warm and friendly atmosphere. Residents spoken with were very complementary about the home and the staff. Comments ranged from “food is generally very good, but I am not a very big eater, although I can request smaller helpings” and “staff are very respectful and knock on my bedroom door and wait for me to invite them in so that I can make myself respectable”. A group of residents who were observed in the lounge to be engaged in general conversation told the inspector they were pleased with the recent decorations, new curtains and armchairs. The care plans seen provided the inspector with evidence that resident’s health care needs are monitored and they have access to health professional such as the general practitioner (GP) and district nurses. A member of staff spoken with informed the inspector that the district nurses are very supportive and offer help and advise whenever it is needed. Prospective residents are able to visit the home for a trial period to see if the home meets their needs. One resident spoken with had been staying at the home for a couple of weeks with a view to moving into Manson house. They were very positive about their stay and commented, “my stay here has been good and people have been most friendly” and “staff are very good”. The home has good accounting and financial procedures in place, which demonstrate the home is well managed, and works within an agreed budget. The Royal Agricultural Benevolent Institute (RABI) has a business plan in place, which is in the process of being updated outlining the future aims and objectives of the home. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 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. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 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 Manson House DS0000032883.V276717.R01.S.doc Version 5.1 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): 1,2,3,5,6, Prospective residents can expect to have the opportunity to try out the home, but cannot expect to have a detailed assessment of their needs completed prior to admission. People trying out or living in the home can expect to have a written contract and statement of terms and conditions. EVIDENCE: The Statement of Purpose seen and has been amended in line with a requirement from the inspection in October 2005. The Statement of Purpose now reflects how residents are consulted about tenants living in the flats who have access to the home’s facilities and how this impacts on the service being provided for residents living in the house. One resident spoken with was staying at the home on a two-week trial period. The resident informed the inspector that the opportunity had arisen just prior to Christmas and although they had already planned to stay with their relative during the Christmas period felt this was a good opportunity to see what the home was like, prior to making a decision to move into the home permanently. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 9 They informed the inspector that they had viewed the home two years ago, with a view to moving to be nearer their family. The resident confirmed their stay “has been good and that people have been most friendly” and that “staff are very good”. Three residents files and care plans were seen, two of the files contained a fully completed pre admission assessment but the third did not. Evidence was seen that a contract was being completed between the resident and the Royal Agricultural Benevolent Institution (RABI). The contract gave clear guidelines of what service the home provided and the terms and conditions of living in the home. The home does not provide intermediate care. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 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, Residents living in the home can expect to have their health and personal needs identified, however those on a trial visit cannot expect to have a detailed individual plan of care, but can expect to be supported to have access to the general practitioner (GP). People living in the home can expect to be treated with respect and have their right to privacy upheld. EVIDENCE: Three residents care plans were seen. Two of the three had details of the resident’s health, personal and social care needs. However the resident on a trial stay had no pre admission assessment or care plan in place or a moving and handling assessment detailing the level and amount of support they required. Evidence was seen on the two other care plans that a detailed moving and handling assessment had been undertaken and these were being reviewed on a monthly basis When the inspector arrived the general practitioner (GP) had been requested to visit a resident whose health was very poor and arrangements were being made for the resident to be admitted into hospital. The manager informed the inspector that the resident had recently become very confused and the GP had made a referral for the resident to see a consultant. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 11 The inspector and the manager had a discussion about the category of registration as the home is not registered for people with dementia and would need to make an application for a variation to the registration should they take any resident into the home with dementia. If the resident is already living in the home and diagnosed with dementia the manager was informed that they need to demonstrate in the Statement of Purpose and Service User Guide that Manson House has a person diagnosed with dementia living in the home and will need to outline the impact this may have on prospective residents and existing residents. They will also need to demonstrate that the staff team receive training in dementia care and the resident’s care plan is reviewed to reflect changes in their needs. Residents are supported to have access to the general practitioner (GP) as requested or if their condition deteriorates. One resident was receiving regular visits from the district nurse to monitor pressure areas and provide care where required. They had arranged for the resident to be issued with pressure relieving equipment and had advised staff on a course of action to prevent further sores occurring. One resident spoken with informed the inspector that they had requested to see the GP to obtain some more medication and had arranged for an appointment for a health check. Entries in the resident’s care plan showed that they had an appointment for the afternoon of the 9th January 2006. A requirement made at the inspection in October 2005 was for the home to keep a separate record of falls and implement assessments detailing the prevention and intervention of falls for residents identified as a risk. There was evidence that the home had contacted a falls co-ordinator through Help the Aged. A coffee morning has been arranged on the 23rd January 2006 for the co-ordinator to visit the home to discuss the risks of slips, trips and falls with the residents, relatives and staff. Following the meeting the manager has arranged for the co-ordinator to discuss with the staff a system for monitoring and the prevention of falls within the home. Another requirement from the last inspection was for the home to obtain information from the pharmacist on the correct storage of eye drops. A copy of the letter obtained from the pharmacist has been forwarded to the inspector specifying how the eye drops are to be stored and evidence was seen that the home are complying with these instructions. Evidence was seen that residents were being referred to by their preferred name and a record of this had been made in their care plan. Residents felt that staff respect their privacy and dignity. One resident commented “I do feel a little vulnerable when using the en-suite in my room as the door concertinas and does not have a lock, but staff are very respectful and knock on my bedroom door and wait for me to invite them in so that I can make myself respectable”. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14, People living in the home are supported to make decisions, choices and have control over their daily lives and a lifestyle that matches their expectations and preferences. EVIDENCE: Residents spoken with told the inspector they were able to receive visitors in private in their own room but said that when a few family members visit together the space in their room is limited. The manager informed the inspector that the library is also available for residents to receive visitors in private and confirmed they would make sure that the resident was aware of this for future visits. The manager discussed with the inspector the process for residents to manage their financial affairs. Some residents are able to manage their financial arrangements themselves and are provided with lockable facilities in their rooms. Other residents have the support of a power of attorney, solicitor or family member. Alternatively the manager has in the past encouraged residents to access advice from support agencies such as Help the Aged. The manager told the inspector that following a recommendation from the last inspection and at the request of the residents they were re-instating regular residents’ meetings. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 13 These are to be held quarterly as a coffee morning and residents and relatives will be invited to share information and be consulted to obtain their views about the home and service provided. A resident who has been at the home for two weeks told the inspector that they had made friends with a few of the residents in the home, “they have been very kind and helpful”, “I have spent time walking in the garden with them and have been invited into a tenant’s flat to join in a game of scrabble” They also spoke of enjoying the arts and crafts sessions and spent their time writing letters to friends. They also commented, “food is generally very good, but I am not a very big eater, although I request small helpings”. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17,18, The home enables residents to exercise their legal rights, however, residents cannot expect to be protected by the homes policy and procedure for dealing with allegations of abuse or current security arrangements. The manager must also ensure that any occurrence or event, which adversely affects the well being of the residents, is reported to the Commission for Social Care Inspection (CSCI). EVIDENCE: Residents are supported to exercise their legal rights. Those who choose to vote have the choice to go to the local polling station in the Church Hall, which is a short walk form Manson House or complete a postal vote. The manager has helped residents to access advocacy services, for example one resident was referred to ‘Help the Aged’ for information, advice and support for their financial situation and what benefits they were entitled to. A requirement from the last inspection for the home’s adult protection procedure to clearly reflect that all allegations of abuse are referred to the Suffolk Vulnerable Adult Protection Committee (VAPC) Customer 1st team and not at the discretion of the manager to decide on a strategy on how to proceed has not been changed and remains a requirement. With the exception of three, all staff have received protection of vulnerable adults training. During the inspection the manager informed the inspector of an event that occurred whereby two intruders were found on the premises. The incident was immediately reported to the police who made a thorough investigation of the premises, but could not find any signs of forced entry. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 15 The police have investigated the break in and a crime prevention officer has visited the home. Following their visits and investigation the home is in the process of reviewing security systems. The manager will be forwarding a completed risk assessment and action plan for the completion of installing new security measures to Commission for Social Care Inspection (CSCI). CSCI had not been notified of the incident, which is a requirement under regulation 37 of the Care Home Regulations. The manager provided the inspector with a formal notification, copies of the police report and crime reduction report during the inspection. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,23, Residents can expect to live in a home that is well maintained and provides a welcoming and friendly atmosphere. EVIDENCE: A tour of the premises was made. The main television lounge overlooking the garden has been redecorated. The inspector discussed the new décor with a group of residents sitting in the lounge. They were very pleased with the new curtains, pelmets and armchairs. However they thought a plain carpet would have looked nicer and wanted some pictures put on the walls. The home and grounds are nicely maintained and provides residents with a comfortable and homely atmosphere. The environment was found to be clean and tidy and had no unpleasant odours. Resident’s rooms seen were clean and tidy and personalised to meet their need and tastes. A requirement was made at the previous inspection for detailed assessments to be made for all residents that had bedrails and bumpers fitted to their bed. Resident’s consent was also to be obtained when using this form of restraint. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 17 The manager informed the inspector that the resident using the bedrails identified at the last inspection had sadly passed away and currently the home does not have any resident requiring the support of bedrails. However the manager confirmed they will make a full assessment should the need arise and obtain consent of the resident. There have been no structural changes to the care home. There are plans to extend the dining room and create a storeroom for hoists and other equipment. The home continues to provide residents with reasonable space in their individual rooms. All bedrooms are single occupancy with en- suite washing and toilet facilities. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 18 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): 29,30, Residents can expect to be supported by a staff team that have received training and support and have the knowledge to care for them. They can also expect to be protected by the home’s recruitment procedures, although staff application forms must contain necessary information relating to their past employment. EVIDENCE: One member of staff was spoken with and their personnel file seen. The member of staff was a regular bank staff worker and covers a minimum of 2-3 shifts per week. They have eighteen years experience of working with the elderly. They spoke highly of the support and training they received working in Manson House and commented, “ I enjoy working here, the level of care provided here is much better than other places I have worked”, “I get much more support from senior staff and the manager”. Their file showed that they had attended recent training, for moving and handling, rights and discrimination and dementia awareness. They also confirmed that they had attended the recent protection of vulnerable adults training. The home has good recruitment procedures in place. The staff member’s file seen showed that the home had a all the necessary paperwork and recruitment checks in place, however the job application form did not reflect their employment history. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 19 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): 34,35,37,38, Residents living at Manson House can be assured that the home has suitable financial and accounting procedures in place and that their financial interests are safeguarded. The home regularly reviews the business and financial plan to ensure the viability of the home. EVIDENCE: The home’s certificate for liability insurance and public liability was seen on display in the manager’s office. The home is insured through the National Farmers Union (NFU) the certificate had recently been renewed and expires on 31st December 2006. The manager explained how they manage the accounting and financial procedures for Manson House. The Royal Agricultural Benevolent Institute (RABI) head office deals with all large bills, but the manager controls the local budget and can approve expenditure up to £1,000. The manager showed the inspector the files for all invoices to do with the operation of the home. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 20 An accountant is employed by the home for one day a week to make sure the invoices are in order and paid appropriately, they also do the staff wages. RABI has their own auditors who inspect the home twice a year and occasionally will have an external audit of the home undertaken. The manager completes a budget annually which is submitted to head office for the trustee’s approval. Once the budget is approved a monthly budget report indicates whether the manager is keeping on line with the agreed budget. The manager showed the inspector their last budget report, which reflected they were just under budget for the year by 1 . RABI business plan for 2003 – 2005 was seen by the inspector, which focused on the aims and objectives, actions and responsibilities of the organisations three homes, of which Manson House is one. The manager explained that RABI is in the process of producing a new updated business plan. The manager will produce a similar business plan for Manson House for 2006- 2007 which will include the refurbishment of the home. The inspector discussed the process for safeguarding resident’s finances with the manager and administrator. Residents that choose to are encouraged to look after their own financial affairs. Safe lockable storage is provided in resident’s rooms. Alternatively a number of residents have a solicitor, power of attorney or family to help them manage their money and affairs. Eleven residents have chosen to have their monies held in the manager’s office. Residents have their own wallet and record of expenditure is kept. The administrator showed the inspector ‘index cards’ where a record of the transactions were made and evidence was seen that two signatures for every transaction were being obtained. However, once the card was full it was being filed away in resident’s archives and did not in all cases leave an accurate audit trail of expenditure for the current balance. Not all expenditure had a receipt to prove where money had been spent. The wallet and balance for one resident was checked and found to be accurate. The inspector was shown a file containing the home’s policies and procedures, which are relevant to the running of the home. A sample selection was seen, which included medication, self-medication, complaints and abuse. The home was seen to keep records of residents and staff in the office in secure filing cabinets and those seen were up to date and accessible with permission from the person and the manager. Residents care plans were kept in the staff office and residents can have access to their care plan on request. Health, safety and welfare issues were highlighted at the last inspection. Requirements were made for the home to ensure the risks to residents were minimised by means of risk assessing areas for example windows with no restrictors and furniture brought into the home by residents not complying with fire safety standards. The home has now fitted window restrictors to all windows were there was an identified risk and automatic fire closures linked to the fire system were seen being fitted during the inspection. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 21 The home has a programme in place to replace existing armchairs with new furniture that meets the fire safety standards. Any new residents will not be able to bring old armchairs into the home; new armchairs will be provided. This has been reflected in the Statement of Purpose. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 22 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 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 2 3 X X 3 3 X X X STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 2 X 3 3 Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 c Sch 3(1)(a) Requirement Each service user must have an assessment of need undertaken which is fully completed that is signed, agreed and dated prior to admission. Timescale for action 28/02/06 2. OP7 15 Sch 3 (1) (b) 3. OP7 13 (4) (5) All new residents entering the 28/02/06 home must have a care plan, which sets out the residents needs in respect to their health and welfare and details of how these are to be met. All residents must have a moving 28/02/06 and handling risk assessment completed and held in their care plan on admission into the home. The registered person must notify the commission of any event in the care home that adversely affects the well-being or safety of the residents. Appropriate procedures must be developed that deal with all allegations of abuse to ensure they are referred to the Suffolk County Council Customer 1st to decide on a strategy on how to proceed. DS0000032883.V276717.R01.S.doc 4. OP18 37 09/01/06 5. OP18 12 (1) 13 (6) 28/02/06 Manson House Version 5.1 Page 24 6. OP29 Sch 4 (6) (f) Any gaps in employment records must be explored prior to appointing a member of staff. 28/02/06 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 OP35 Good Practice Recommendations Where the money of an individual resident is handled, the manager should make sure that appropriate records and receipts to allow an audit trail of all financial transactions. Manson House DS0000032883.V276717.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Manson House DS0000032883.V276717.R01.S.doc Version 5.1 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. 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