Inspection on 21/10/05 for Manson House

This inspection was carried out on 21st October 2005.

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

Manson House 22/11/07

Manson House 26/02/07

Manson House 08/05/06

Manson House 13/01/06

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 21st October 2005 09.20 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.V258740.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 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.V258740.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th March 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.V258740.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.20am. It took place over seven and half hours during a weekday. Time was spent with the manager and the team leader. A tour of the premises was made and a number of records were examined including those relating to the care of residents and staff and a selection of policies and procedures. The inspector spent time talking to 11 residents individually and was invited to join the residents for lunch in the dining room. Two relatives were visiting on the day of the inspection and were spoken with separately. What the service does well: What has improved since the last inspection? To protect the residents safety and welfare the home has fitted radiator guards to all radiators throughout the home and have window restrictors fitted on all windows where there was a risk to residents, however two windows in the bathrooms above the ground floor had been missed. Risk assessments have been produced in line with the home’s medication policy for residents to self medicate and safe lockable cabinets have been fitted in resident’s rooms to keep medication and small valuable items. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 6 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.V258740.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Residents can expect to have their health and personal needs identified before moving into the home, but cannot expect the assessment paperwork to be fully completed and signed and dated. Residents can expect to visit the home prior to making a decision where to live. EVIDENCE: The home has a detailed statement of purpose and service user guide which is produced as a “Residents Handbook”. These documents are well presented and provide prospective residents with information about the home. However, at the rear of Manson House the Royal Agricultural Benevolent Institution (RABI) provide 19 sheltered flats. A requirement from the previous inspection was for the statement of purpose to be amended to reflect how residents of Manson House are consulted about the tenants of the flats accessing facilities within the home. Residents have been asked through satisfaction questionnaires their opinion of the people from the flats visiting the home and using the facilities. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 9 A selection of questionnaires was seen and residents comments were that it is “good to have contacts with the outside world and not be a closed community of ageing people” and that “they were very much in favour”. The statement of purpose makes reference to residents from the flats joining in with some of the social activities and festive occasions, however it does not reflect how residents have been consulted and what support is provided by the home to the flats and how this may impact on the residents within the home. Three residents files and two care plans were inspected. Two residents had recently moved to the home and another was due to move in the day after the inspection. All had a needs assessments, prior to their admission, on file, however one was not fully completed or signed and dated, but did have detailed information about the care needs recorded in their care plan. One service user who had lived at the home for two weeks, told the inspector that “staff were ever so kind, and that they had made me feel welcome” Each of the residents had a contract signed and dated between them and Royal Agricultural Benevolent Institution (RABI). The needs assessments formed the basis of the residents care plan and covered areas around their physical and emotional and social well-being. Residents have the opportunity to visit the home prior to moving in. One resident had stayed for a period of respite and had decided to stay and another resident had frequently visited the home to visit a relative that previously lived at the home. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Residents can expect to have their health and personal needs identified, and reviewed. However, the safety of the residents cannot be assured with until risk assessments are completed to minimise the risks involved in moving and handling and prevention of falls. EVIDENCE: At the front of each plan was an assessment sheet with the details of the resident’s next of kin and general practitioner (GP) and previous medical history and known medical conditions. The care plans were made up of different sections, which included issues around the resident’s social and health and personal care needs. Each of these headings was further explored in detail to form the care plan focusing on the resident’s assessed needs and evaluation of the support required. Evidence was seen on the care plans of detailed moving and handling risk assessments identifying the resident’s individual needs and necessary equipment, however, one resident that had recently moved to the home had not had a risk assessment completed. Evidence was seen that these risk assessments were being reviewed on a regular basis. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 11 Daily records and entries in the accident book show that there are a significant amount of residents falls being recorded. The manager informed the inspector that they had recently been in contact with a falls co-ordinator to arrange for staff training and assessments of residents. No residents at the home were being treated for pressure sores at the time of the inspection, however details seen in one resident’s care plan showed that they had been issued with an air mattress and cushion from the district nurse to prevent them developing pressure sores. The inspector observed a senior member of staff administering medication. The home uses the Boots monitored dosage system (MDS). All medication administration record (MAR) charts were completed accurately. The medication was kept in a lockable portable medicine trolley which is kept locked in the staff office when not in use. The home holds a small amount of controlled drugs that were locked in a separate secure cupboard. The controlled drugs book was seen and a random check of one service users drugs and amount of medication held was correct. Eye drops were being stored on the medication trolley and the member of staff informed the inspector that they had been advised by their pharmacist that the eye drops did not need to be stored in the fridge, however the instructions on the label advised that they be stored at a temperature between 2 – 8 degrees centigrade. The eye drops had a date recorded on the box of when they were opened to make sure that they were not being used passed their timescale. Evidence was seen that risk assessments have been introduced for residents that self medicate. The risk assessment states that the residents are supported to administer their own medication and provided with a lockable metal cabinet in their room for them to hold their own medication. A senior member of staff reviews the resident’s capability on a regular basis. Residents spoken with throughout the day informed the inspector that in their experience the staff respected their privacy and dignity. This was also confirmed when talking with resident’s relatives and by observation throughout the day. Evidence was seen that residents are supported at the time of their death in accordance with their wishes; a letter was displayed on the staff notice board from a relative thanking the staff for looking after their relative. The manager informed the inspector that the priest had been requested and visited the resident to administer last rights. One resident had their wishes documented in their care plans that in the event of serious illness. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Residents can expect to live in a home that supports a life style that matches their expectations. Residents can expect to receive a good standard of food with a variety of choice as part of their daily diet. EVIDENCE: On the day of the inspection the home was commemorating the battle of Trafalgar, which has, it’s 200 year anniversary this year. The manager had created a display board with the historical facts and had displayed it in the dining room. To join in the celebrations the kitchen had reproduced a menu from that time, of salmon and watercress sauce with vegetables followed by william pears in red wine and cinnamon with yogurt and honey. There were also plans for the home to light a candle that evening to represent the lighting of a beacon that was taking place across the country. The inspector joined residents sitting in the library enjoying their morning coffee and was able to speak with residents about their experiences living in the home. One resident told the inspector that they had recently been to an art exhibition in Bury St Edmunds cathedral and attended art classes locally. Other residents spoke of playing scrabble and cards and in summer months playing croquet in the garden. They spoke of outings to Felixstowe and Monks Eleigh to visit a dried flower farm. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 13 One resident told the inspector that they have a hog roast donated every year and have this around the end of October to celebrate halloween and fireworks night. A volunteer visits the home weekly to hold a handicraft session. Residents spoke of joining in making cards and were proud to show the inspector a selection of beautiful hand made christmas and birthday cards. Other activities available were listed on a board in the front entrance and included keep fit every Friday and listed dates for services of different religions within the home. The librarian visited fortnightly and all residents including those living in the flats within the grounds were invited to attend sherry and nibbles in the library on a Sunday morning before lunch. The home has two papers delivered, the Daily Mail and East Anglian Daily Times and on a Friday the Bury Free Press. One resident requested and has the Telegraph delivered for them personally. Residents sitting in the library were unaware of the time and date and thought it would be helpful to have a clock and calendar with large bold letters. The visitors book showed that relatives were seen to visit frequently. The inspector was able to meet with two relatives on the day of the inspection who spoke of staff being very approachable and felt that their relatives were well cared for. Residents spoke of the home as “very nice here” and “it is a lovely home, we can wander about where we like which makes it like home” and “staff are very good, I have a very comfortable room and the food is very good”. The inspector was invited to join the residents for lunch and was able to take part in a conversation about the home and the food. The celebratory lunch was well received and residents had a choice of a glass of wine with their meal. Residents who had not wanted the salmon for lunch had chosen to have bacon and egg as an alternative and there was also a choice of rice pudding for dessert. The food seen looked appealing and appetising. Residents commented that the food was “very good” and ”splendid and marvellous choice”, however one resident commented it would be better if there was more than one person to bring their food to the table from the kitchen so that they did not have to wait. One resident spoken with told the inspector that they were given a menu the day before to choose what they wanted to eat tomorrow and that they had chosen chicken casserole followed by apples and custard for lunch and a Tuna salad for their tea. Another resident spoke of having a high tea and had had sausages and fried potatoes and a yogurt the previous evening. During the afternoon residents were served with tea and biscuits. Residents with special needs were catered for, one resident with Parkinson’s had been provided with specially adapted cutlery to enable them to maintain their independence and ability to feed themselves. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Service users can expect to have their complaints listened to, however cannot expect to be fully protected from abuse until the home has amended the procedure in place for the management of allegations of abuse. EVIDENCE: The home had received two complaints since the last inspection in March 2005. The complaints book was seen and the complaints had been logged and action had been taken to investigate the complaints made. One complaint had been unsubstantiated, however investigation of the other complaint was still being made about the conduct of a member of staff in line with the complaints policy of the Royal Agricultural Benevolent Institute (RABI). The home has a detailed policy that deals with the management of allegations of abuse, however the policy states that the manager will take personal responsibility and decide whether the alleged abuse might constitute criminal action, which will need reporting to the police. This needs to be reviewed, as it does not make clear that all allegations of abuse should be referred to the Suffolk Social Care as an adult protection matter (VAPC) who will take the lead on the incident and advise the home accordingly. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25, 26 Residents can expect to live in a well-maintained and welcoming environment, which provides a good range of communal and personal accommodation. However, the safety of the residents cannot be assured with until risk assessments are completed to minimise the risks involved the appropriate use of bedrails. EVIDENCE: The home is situated in the town and is in close reach of the shops and abbey gardens. Manson House has a homely feel and is nicely presented both inside and out; all areas of the home were nicely decorated and clean and tidy. The home is on three floors and has access by a passenger lift and two stair lifts. Communally there is a range of facilities available. A large sitting room is situated to the rear of the house overlooking the garden. There is a spacious library and a dinning room. There are plans in progress to extend the dining room and to create a storeroom for hoists and other equipment. A donation has been made to Manson House through the Royal Agricultural Benevolent Institute (RABI) and there are plans to refurbish the sitting room replacing the wallpaper, curtains and armchairs. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 16 All bedrooms are single occupancy and have en-suite toilet facilities. There are three assisted bathrooms and a walk in shower. The home has three other toilets in addition to the en-suite facilities. Eleven of the bedrooms were seen during the inspection and all were tastefully decorated and furnished with resident’s own belongings. The home provides accommodation for 24 residents but currently have 23 residents living at the home, the spare room has an ensuite shower and to maintain the safety of residents in the home the water supply had been turned off to reduce the risk off legionella occurring. Evidence was seen that specialist equipment had been provided. One resident with hearing difficulties had been given a deaf guard by the fire officer on a trial basis to alert the resident in case of fire during the night. The resident informed the inspector that the deaf guard was placed under the pillow and was linked with the fire system. The guard vibrates and lights up in the event of the alarm being sounded. They told the inspector that they did not find it helpful as the device had slipped from under their pillow and they had not liked the strobe lighting. Another resident had side rails and bumpers fitted to their bed, however the home did not have a risk assessment in place to demonstrate that the bed rails were compatible with the bed or that they had obtained the resident’s consent to use this form of restraint to prevent them falling out of bed. The home has two laundry rooms situated on the first and second floors, each have a washing machine with a sluicing facility. The home uses red dissolvable bags for the soiled laundry, which are put directly into the machine for sluicing. Staff have access to hand washing facilities with liquid soap and paper hand towel dispensers situated in every bathroom. Air fresheners have been fitted which give off a nice fragrance throughout the home. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Residents can expect to be supported and protected by a staff team, who have received training and have the skills and knowledge to care for them. Residents can expect to be cared for by a team who are available in sufficient numbers to meet their needs. EVIDENCE: Staff rotas were seen; the home operates with 1 senior and 2 care staff on the early and late shifts. The early shifts are between 7.30am – 2pm for the carers and 7.30am – 2-30pm for the senior. The late shifts are staggered between 2pm and 8pm and 9-15pm with an additional member of staff assisting with afternoon tea. Two night staff work between the hours of 9pm – 7.30am and have a sleeping in member of staff for support in case of emergencies. The home has 2 cooks and a team of 5 domestic staff and 1 full time maintenance person. On the day of the inspection 1 cook was working 8.30am – 2pm and 3 domestics between the hours of 8am – 1-30pm, 1 was designated to looking after the laundry. The maintenance person was working 8am – 3pm. Two staff files were seen. All the necessary paperwork and recruitment checks were in place. Evidence was seen on the file of an induction programme for a new member of staff for their first week of employment in the home. The other file seen had certificates showing that the member of staff had completed the sector skills council for social care (TOPPS) induction and foundation courses. Evidence was seen of other core training that had taken place, which included moving and handling, communication, food hygiene, rights and discrimination. and fire safety. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 18 Training records seen on the staff files showed training had taken place related to the care of the residents, which included causes and management of pain, dementia awareness, continence and the ageing process which covered topics of common aliments of the elderly and national vocational qualifications (NVQ) at level 2 and 3. One member of staff told the inspector they were working towards the completion of level 4. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 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): 31, 32, 33, 36, 38 Residents can expect to live in a home that is well managed, but would like to have regular residents meetings to and be more involved in the running of the home. Residents cannot expect their health and safety and welfare to be protected until action has been taken to assess the risk of non fire retardant furniture and windows in the bathrooms on the upper floors not fitted with restrictors. EVIDENCE: The manager of the home has forty years experience in the care of the elderly and holds a national vocational qualification (NVQ) level 4 in management. They are supported by a deputy manager who is responsible for the running of the home in their absence. The deputy has recently taken up the post and is currently working to achieve their NVQ 4. Residents and staff and relatives spoke of the manager as being honest, open, supportive and approachable. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 20 Staff files showed that regular supervision is taking place where aims and objectives are discussed and recorded and observation of staff carrying out specific tasks with documented feedback. The notice board in the staff room had the date of a staff meeting and an agenda attached. Evidence showed that the manager sought the views of staff in the running of the home by adding a request for staff comments and items they wished to be raised at the meeting. The statement of purpose makes reference to monthly residents committee meetings. Residents were asked if they had regular meetings to discuss issues in the home. They informed the inspector that they have a meeting held in spring to put forward their suggestions for activities and outings they wanted for the coming year. However, did not recall regular meetings. One resident told the inspector that they thought it was “awfully important to air out their views about the home”. Resident and visitors are able to give feedback about the management of the home and services provided in satisfaction questionnaires. A number of residents questionnaires had been completed and returned to the manager. Feedback was mostly good and comments included “ I count myself fortunate to live here” and “ I am very well looked after”. A resident had been supported by a relative to complete the questionnaire and had made joint comments, that they had no complaints and were very happy with the way the home cared for the resident. One resident had made comments on the questionnaire that they were not happy with the size of their room as they had too little space. The home had acted on this feedback and had moved the resident into a larger room. This resident was spoken with during the inspection and was very happy with their new room. To meet requirements from the previous inspection the home has installed lockable safe storage cabinets in each of the bedrooms for residents to keep personal items and money and medication. They have also fitted radiator guards to all radiators throughout the home. Windows in bedrooms on the first and second floors where there was a risk to residents have been fitted with window restrictors, with the exception of one resident who liked to have their window open. The resident has written a letter stating that they do not wish to have restrictors fitted to their window, which has been placed on their file. Two bathrooms on the first floor were found not fitted with restrictors. A requirement made at the previous inspection was for the home to balance the wishes and rights of residents against health and safety requirements when bringing their own items of furniture into the home. The manager informed the inspector that all new residents are provided with fire retardant furniture in their rooms however; residents with existing furniture are still at risk in the event of fire. The homes risk assessment does not cover this issue and will need to be amended to assess the risk to residents. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 21 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 2 3 2 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 3 3 3 2 x 3 3 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 3 3 2 X X 3 X 2 Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 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. The statement of purpose must reflect all facilities and services provided by the home, including how residents have been consulted and the support provided to the flats. A copy of the revised statement of purpose must be sent to the CSCI. All residents must have a moving and handling risk assessment completed and held in their care plan. A record of falls and assessments for the prevention and intervention of falls must be kept for residents identified as at risk of falling. The manager must consult their pharmacist and obtain in writing the correct storage for eye drops. A copy of the letter to be sent to the CSCI. Timescale for action 23/12/05 2 OP1 4,1,b, 23/12/05 3 OP7 13,4,5,15 23/12/05 4 OP8 Sch 3 (3)(o) 23/12/05 5 OP9 13,2, 23/11/05 Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 23 6 OP18 7 OP22 8 OP38 9 OP38 12,1,13,6, 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. 13,4,c, A risk assessment needs to be undertaken to determine the use of bedrails and the risks to the resident. The resident’s agreement must be sought when using this form of restraint. 13,4, Remedial action to be taken to the windows in the bathrooms above the ground floor in line with the homes risk assessments to ensure that risks to residents are minimised. 23,4,a, The manager must review the home’s fire risk assessment with regards to resident’s own existing furniture. The risk assessment needs to identify how the home can meet fire safety requirements and the safety of all residents in the home. 23/12/05 23/11/05 23/11/05 23/11/05 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 OP33 Good Practice Recommendations Resident’s views and opinions about the home should be sought at regular resident committee meetings as described in the statement of purpose. Manson House DS0000032883.V258740.R01.S.doc Version 5.0 Page 24 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.V258740.R01.S.doc Version 5.0 Page 25 - 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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