Inspection on 10/01/07 for Morris Feinmann House

This inspection was carried out on 10th January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Morris Feinmann House 05/02/06

Morris Feinmann House 25/08/05

Morris Feinmann House 03/02/05

Morris Feinmann House 21/09/04

Morris Feinmann House 24/03/04

Morris Feinmann House 10/11/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Morris Feinmann House 178 Palatine Road Didsbury Manchester M20 2YW Lead Inspector Geraldine Blow Unannounced Inspection 10th 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 Morris Feinmann House DS0000021565.V326887.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. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Morris Feinmann House Address 178 Palatine Road Didsbury Manchester M20 2YW 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) 0161 445 3533 0161 448 1755 heather@morrisfeinmannhome.com Morris Feinmann Trust Mrs Heather Flora Naylor Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (57) of places Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The maximum number of service users within the overall total of 57 requiring nursing care shall be 22. The maximum number of service users requiring personal care only shall be 35. The Levy wing accommodates only service users requiring nursing care. Minimum nursing staffing levels as set out in the Notice issued under Section 25(3) of the Registered Homes Act on 8 January 2002 shall be maintained. That a First level Registered Nurse trained in General Nursing will be in charge of each shift. In addition to the General Manager the service provider employs an identified full time First level Nurse trained in General Nursing who is responsible for the clinical supervision of the nursing staff in the home. The service must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 5th February 2006 7. Date of last inspection Brief Description of the Service: The Morris Feinmann Home provides nursing and social care for up to fiftyseven (57) residents on a long or a short-term basis. Registration is currently for thirty-three (33) receiving care only and twenty-two (22) residents receiving care with nursing. The home admits Jewish residents aged over sixty years from the local community, other areas of Britain and from abroad. The home is divided into three wings and a central area. The Palatine and Spath wings comprise of residential care beds and the Levy nursing wing is for high dependency nursing care. The central area comprises of the administration block, hallway and reception. The home is situated in a residential area of Didsbury, set back from a main road. Car parking areas are provided. Lawned areas, gardens and mature trees and shrubs surround the home. Bus routes to the city centre and surrounding towns pass the home with bus stops a hundred yards from the main entrance. The current fees range from £565.00 to £865.00 per week. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 5 Further information about the home can be provided by contacting the home direct. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 5 February 2006. The home did not submit the pre-inspection questionnaire, requested by the CSCI, for supporting information. This visit forms part of the overall inspection process and was conducted by 2 inspectors and took place on Wednesday 10 January 2007. The opportunity was taken to look at all the key standards of the National Minimum Standards (NMS) and the requirements made at the inspection on 5 February 2006. This inspection was also used to decide how often the home is to be visited to make sure that it meets the required standards. As part of the visit time was spent with the residents who live at the home, observing how staff work with residents, discussions with staff and the registered manager, assessing relevant documents and files and a tour of the premises was undertaken. No complaints or concerns were received by the CSCI in relation to the home. What the service does well: The home offered a clean and pleasant environment for the residents who lived there. One comment received was that “the home is always clean, it can’t be faulted.” The atmosphere in the home felt happy and relaxed. Residents were seen to be sat talking together and enjoying each other’s company. From observations made and from talking to residents and staff, it appeared that the privacy and dignity of residents was protected and that residents were able to have choice with regard to their every day life. The staff were seen to be kind and patient and residents spoken to were positive with regard to the staff. One resident said, “the staff are absolutely marvellous”. The home carried out a pre admission assessment before a resident was admitted to the home to make sure that the home could meet the person’s needs. The home had an open visiting policy and residents and staff spoken to confirmed this. One resident said, “my family are always made to feel very welcome and can visit at any time.” From talking to staff and residents it appeared that families were kept fully informed of any issues regarding the residents. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 7 Meals met the residents’ cultural needs and a good choice was available and these were served in well maintained dining rooms or the resident’s own room if that was their wish. A choice of meals was available at each mealtime and those residents spoken to indicated that they were happy with the quality and quantity of food. The home provided a wide range of social activities, which residents could participate in if they wished. The activities varied for example from trips out to bingo, exercise sessions, bridge and one to one activities. On the day of this visit some residents were seen to be enjoying a game of bridge in the morning and then in the afternoon other residents were seen playing bingo. Volunteers who came into the home provided regular live music and other activities. As the home caters exclusively for Jewish residents a number of religious services were held in the home. Systems were in place to support residents or visitors to make a complaint. What has improved since the last inspection? What they could do better: Although residents had individual plans of care it was found that some of the plans had not been updated to reflect the current needs of the resident. Several recommendations have been made in relation to the residents individual plans of care. For example, the plans should contain more detail to provide clear guidance to staff of the actions to be taken to meet the residents health and welfare needs and that evidence should be provided of how and when residents and family are involved in developing, updating and reviewing Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 8 the care plan. Also it is recommended that the plans of care maintain and promote the independence of residents. The home needs to improve the way it records medication given to residents to ensure that an accurate record is kept of all prescribed medication given. In order to fully protect the residents accommodated at the home improvements are needed to the recruitment procedure to make sure they have undertaken all the required checks and received the necessary information before a person starts work at the home. The home appears committed to providing the staff team with the skills and training needed to support residents and is currently doing an audit to find out what the training needs are of the staff. This audit must be completed and a training plan must be developed based on the results of the audit. To make sure that the home is run in the best interests of the residents the home must develop a system for reviewing the quality of care being provided by the home and develop a written policy and procedure for supporting and managing residents personal monies. 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. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 9 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 Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: The home had a documented pre admission assessment form based on the local Primary Care Trust nursing assessment, titled “Nursing Needs Assessment”. This assessment was used to ensure that prospective residents were only admitted on the basis of a full assessment of need being carried out. At the previous inspection it was identified that assessments in the home, which were in depth, were nursing orientated. Whereas this was obviously appropriate on the nursing unit, it is recommended that the form be reviewed and amended for the residents assessed as requiring personal care only to ensure that their specific needs are assessed. The manager stated that the home was in the process of developing their own residential care preadmission assessment format to take into account prospective residents’ nonhealth related needs. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 11 The home had access to a range of health care professionals, including consultants, who can undertake specialist assessments prior to offering a place at the home. This helped the home identify specific health related needs and decide whether they could be met. The manager said that the majority of residents were self-funding, however the manager said that for those residents who were referred through Care Management arrangements the home obtained a summary of the Care Management Assessment prior to admission. Where possible, prospective residents and their family/representative were encouraged to view the home prior to making a decision about admission. The home did not provide an intermediate care service Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident had an individual plan of care. However, some areas of the plan required improvements to ensure residents’ health, personal and social care needs are fully met. The systems and procedures for dealing with medicines needed some improvement to protect residents. EVIDENCE: A random sample of care plans were examined. It appeared that each resident had an individual plan of care, however some shortfalls were identified. It was found that some of the assessment forms had not been completed. For example in one file examined a number of risk assessments such as falls risk assessment, fracture risk assessments and nutritional risk assessments had not been completed. In another file it was noted that the resident had bed rails in situ, however the risk assessment for the use of bed rails had not been completed. Unnecessary risks to the health or safely of residents must be identified and so far as possible eliminated. It was found that some of the plans of care were vague and did not set out in detail the actions which need to be taken by care staff to ensure that all Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 13 aspects of residents health, personal and social care needs are met. For example, “assistance of 2 to mobilise” and “2 staff to assist with body wash”. Residents care plans should be written with sufficient and accurate detail to provide clear guidance to staff of the actions to be taken to meet the residents health and welfare needs. In addition the plans of care were not seen to promote independence of the resident. To promote the wellbeing of residents it is recommended that the plans of care maintain and promote the independence of residents. It was of concern that specific care needs of residents had not been included in the plan of care. For example, it was clear from talking to staff and reading the daily logs that one resident could be quite aggressive. The aggressive behaviour had been recorded however there was no care plan on how to manage that resident’s behaviour and no risk assessments had been competed. The manager and the staff said that care plans were reviewed every 8 weeks, however, it was noted that care plans had not been updated to reflect the current needs of the residents. For example one plan of care made reference to the resident having a plaster of paris in situ and gave details of how the resident could mobilise with the plaster of paris. However the plaster of paris had been removed and the care plan had not been updated to reflect this and another care plan stated that the resident required the assistance of 2 carers to mobilise. However the staff and the manager said that the resident could mobilise unaided. The care plan had not been updated to reflect this. It was identified in one care file that the resident had been admitted to the home in November 2006, however the risk assessments and care plans were dated August 2004. It is recommended that each new admission to the home generate a new assessment of needs and care plan. It was obvious from talking to staff and residents that residents and families were involved in the developing the care plans and were kept fully informed of any issues or changes to care needs. However this was not supported by documented evidence. It is recommended that the home make sure that a clear record is made and evidence of how and when residents and family are involved in developing, updating and reviewing the care plan. The home had a ‘Care Committee’ consisting of a number of health professionals, including consultants in different specialisms, who can be asked to provide assessment and treatment guidance in relation to residents’ identified health needs. The home previously had a dedicated G.P but since the previous inspection this has changed and now all residents are registered with a local G.P Practice. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 14 Most of the Medication Administration Record Sheets (MARS) were clear and accurate and provided evidence that medicines were being administered as prescribed. The records showed that most medications could be accounted for by means of a clear audit trail. However the home needs to make improvements in how they record when creams are applied. For example it was noted that ‘F’ had been recorded for the majority of creams. The sister of the unit said that ‘F’ was recorded when care staff had applied the cream. However the code on the bottom of the MAR sheet stated ‘F’ was ‘other’ and must be defined. However the code was not being adhered to and therefore it was not clear if the resident had, had the cream or if not. In addition it was noted that one resident had been prescribed ‘Thick and Easy,’ which is an agent to thicken fluids for people who have swallowing problems. There was a letter from the Speech and Language Therapist detailing that the need to thicken the residents fluids. No recording had been made on the MAR sheet to evidence if the agent had been used or not. The sister in charge said that the resident had been refusing to have the thickening agent. There was no documented evidence to support this claim. In order to ensure that residents care needs were being met appropriately an accurate record should be maintained of each drink / soup etc that had been thickened and any other liquid the residents may have had to drink or an explanation should be given as to why the thickening agent has not been used. It was noted that hand written entries on the MAR sheet had not been signed by the staff member making the entry and evidence could not be provided why a change in the medication administration time had been made. From observations made during the inspection and discussions with residents and members of staff it appeared that the nurses and care staff treated the residents with respect and dignity. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A wide range of activities were provided and residents were able to maintain contact with family and friends. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: The home had a good programme of activities six days a week supported by a number of activities organisers who work throughout the home including the nursing unit. On the day of this visit residents were seen enjoying a number of different activities throughout the day and one resident spoken to confirmed that she enjoyed the variety of activities available to her. As the home caters for Jewish residents this was reflected in a number of religious services held in the home. Residents were consulted about their social interests and personal preferences and the manager said that attendances of activities was recorded in the residents individual daily logs. From observations and from speaking to staff and residents it was evident that residents were encouraged to exercise choice and control over their day-to-day lives and that residents were encouraged to bring personal possessions into the home. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 16 Close links with the community were maintained and the home had a number of volunteers and an excellent news magazine. The manager and staff said that the home facilitated open visiting and visitors were made welcome in the home. Residents spoken to confirmed this. The home serves kosher food and the menus showed that there was always plenty of choice. Residents spoke highly of the meals and confirmed that plenty of choice was available to them. Residents did choose prior to the meal what they wanted but if they changed their mind when this was served this was readily accommodated, and if the resident did not want the main choices other lighter options were suggested and made available. Meals could be taken in any of the dining rooms or in the privacy of the resident’s own room. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home encouraged and supported people to raise their concerns and complaints. However to protect the resident from abuse the appropriate procedures for reporting suspected abuse should be followed. EVIDENCE: The home had a complaint procedure, which was included in the Service User Guide, which residents had been given a copy of and in addition the manager said that all residents were given a copy following a residents meeting in 2006. A record was kept of all complaints made and included details of the investigation and any action taken. The manager said that she encouraged resident/relatives to bring any concerns to her so that they could be addressed as a priority. Residents spoken to confirmed that they felt comfortable if they had to make a complaint. No complaints had been made direct to the Commission since the last report. The home had a copy of the local authorities “No Secrets” guidance and the manager said that all staff had now attended Protection of Vulnerable Adult (POVA) training. Since the previous inspection an incident occurred at the home that needed the involvement of the police. The manager described the incident and the actions taken to try to resolve the issue. The manager had not made a referral under the local Adult Protection procedures and acknowledged that this incident should have been reported to the local authority and the CSCI had not been informed of the incident. The POVA procedure was Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 18 discussed at length with the manager. The home must ensure that they follow the locally agreed adult protection procedures and in accordance with Regulation 37 of The Care Homes regulations 2001 the CSCI must be informed of incidents detailed within this Regulation. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All areas of the home were clean, comfortable, well maintained and equipped to meet the needs of the residents. EVIDENCE: The home provided a clean, comfortable environment decorated and furnished to a high standard. There were a variety of communal areas for residents to use which included a hair dressing room, a Carebach room where synagogue services were held and a newly built cinema/activity room and private wellmaintained grounds that were accessible to all residents. Each floor of the home provided a small kitchenette for residents or relatives to make drinks or snacks. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 20 Residents spoken to said that the home was always “nice and clean and she especially liked her room in the summer because she had her own balcony which she and her family could sit out on and enjoy the nice weather.” Bedrooms were nicely decorated and personalised with items brought in from resident’s own homes. The laundry room was situated in the basement away from food preparation areas. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff available appeared sufficient to meet the residents assessed needs. The homes recruitment procedure did not fully protect the residents accommodated. EVIDENCE: At the time of the inspection site visit the home’s staff team consisted of a team for residential care, one for nursing care and a night staff team. The residential care side consisted of care team leaders and care workers and the nursing side consisted of qualified nursing staff and care workers. From the evidence seen the home showed that they were providing sufficient staff to meet residents needs. The levels of staff are determined by the numbers and needs of residential and nursing residents. These levels should be reviewed on a regular and ongoing basis to ensure that staffing levels meet the assessed needs of residents. The home was in the process of changing their National Vocational Qualification (NVQ) provider and therefore no staff were currently undertaking the NVQ level 2 qualification. Information provided by the home showed that 14 of the staff team had the NVQ level 2 or above. It is recommended that the home implements a vocational training programme to provide its staff team with the required vocational qualifications. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 22 A sample of staff files was examined to see if the recruitment process generated the information and documentation required under the Care Homes Regulations 2001. A staff file seen only contained one reference and this reference was not signed or dated. The home was about to introduce a new recruitment checklist to ensure that all the correct information had been gathered prior to a person starting work at the home. However, the home must ensure that they have undertaken all the required checks and received the necessary information prior to a person starting work at the home. The home has a system for reminding qualified nurses when their registration requires renewal. All PIN numbers are checked prior to nursing staff starting work. Evidence was seen that all relevant staff have a Criminal Records Bureau Disclosure certificate. Staff training consisted of an initial 6-week Induction programme that looked at key areas such as Moving and Handling, Emergency First Aid, Fire Training and relevant policies and procedures. In addition, there were mandatory training events that all staff should attend to refresh their skills. The home is currently undertaking an audit of all the training that staff have participated in to find out any gaps in individual and staff team training needs. To make sure that the home have a clear picture of all staff training and refresher training needs they must complete the training audit and develop a training plan based on the findings of the audit. The home was committed to providing the staff team with the skills and training needed to support residents. Evidence was seen of a range of training events that care workers and nurses had attended over the last 12 months. The home maintained good links with the local Primary Care Trust (PCT) to access their training events as well as other training providers. The home operated a system where a named member of staff had specific responsibilities in key areas such as diabetes and other health related areas. However, it was unclear how the training and information they gain is cascaded down to all relevant staff. It is recommended that the home develop a system for cascading training and information down to all relevant staff. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from a committed and caring manager. A formal quality assurance system must be implemented to ensure the home is run in the best interests of the residents. EVIDENCE: The General Manager of the home is also the registered manager and has overall responsibility for the management and operation of the home. She demonstrated a clear understanding of the need to continually develop the care service in the best interests of the residents and the necessity of continued staff support. The management structure consisted of a Care Manager who is responsible for the delivery of nursing and personal social care, a Night Manager, and an Office Manager responsible for administration and the domestic service. Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 24 The homes management structure had clear lines of accountability and responsibility and operated a well run home. The home has not yet developed a formal quality assurance system to look at issues of quality within the service. There is an informal system where the home holds monthly meeting where residents and their relatives can attend to talk about the service received and any issues or problems they are experiencing. In addition, residents can talk to the management on an individual basis about any issues relating to the quality of the service. The home is aware of the need for monthly site visits by the responsible individual and/or their representative. However, these have not occurred for the past 6 months. The home must implement a formal quality assurance system that includes undertaking the required Regulation 26 visits and produces an annual development plan. The home support a number of residents to manage their personal monies. Money is kept on their behalf and used to pay for personal items, hairdressing and other activities such as social events. The financial recording system maintains a record of all residents spending. Receipts are maintained and the records and balances are checked on a regular basis. It was found that part of the financial system involved recording all residents spending within a single log. This is a breach of the Data Protection Act. Although the majority of residents spending was matched with a signed receipt there were some examples, such as group social trips, where the residents contribution had not been receipted or signed by the resident. The home had not developed a written policy and procedure for supporting and managing resident’s personal monies. A clear policy and procedure must be developed setting out the recording, auditing and monitoring systems. Evidence was provided that the home’s maintenance certificates and records were up to date to ensure the health, safety and welfare of the residents and staff are protected at all times. Morris Feinmann House DS0000021565.V326887.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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 x x 3 Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15 (2) (b) 13 (4) (C) Requirement 1. Each resident must have a written plan of care setting out how individual resident’s needs in respect of their health and welfare are to be met. 2. The plans of care and risk assessments must be accurately reviewed and updated on a regular basis to reflect the current needs of the resident. 3. Each resident must have appropriate risk assessments completed to ensure that unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. To ensure the health, welfare and safety of residents the registered provider must ensure that accountability for all medication is evidenced by accurate record keeping. 1. The registered provider must ensure that the home follow the locally agreed adult protection procedures DS0000021565.V326887.R01.S.doc Timescale for action 28/02/07 2. OP9 13 (2) 31/01/07 3. OP18 16 (6) 37 (f) 31/01/07 Morris Feinmann House Version 5.2 Page 27 4. OP29 5. OP30 6. OP33 7. OP35 2.The registered person must inform the CSCI of any incidents detailed within Regulation 37. 19 (5) (i) The registered provider must Schedule ensure that two written 2 references are obtained before appointing a member of staff. 18 (1) (c) To make sure that the home (i) have a clear picture of all staff training and refresher training needs they must complete the training audit and develop a training plan based on the findings of the audit. 24 (1) (a) The registered provider must 26 (2) (4) implement a formal quality (a) (b) (c) assurance system that includes (5) (a) (b) undertaking the required Regulation 26 visits. 13 (6) The registered provider must ensure the home develops and implements a written policy and procedure for supporting and managing resident’s personal monies, which includes the procedure for the recording, auditing and monitoring systems. 31/01/07 12/03/07 31/03/07 28/02/07 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 OP3 Good Practice Recommendations It is recommended that the pre admission assessment for residents assessed as requiring personal care only be reviewed and amended as the current assessment is titled “Nursing Needs Assessment”. 1. It is recommended that the home make sure that a clear record is made and evidence of how and when residents and family are involved in developing, updating and reviewing the care plan. DS0000021565.V326887.R01.S.doc Version 5.2 Page 28 2. OP7 Morris Feinmann House 2. It is recommended that previous admission assessments and care plans are not used and that each new admission generates a new assessment and care plan. 3. It is recommended in order to promote the wellbeing of residents the plans of care maintain and promote the independence of residents. It is recommended that any hand written entries on the MAR sheet is signed by the person making the entry and they are backed up by a fax from the GP confirming the change. The levels of staff are determined by the numbers and needs of the residential and nursing residents. These levels should be reviewed on a regular and ongoing basis to ensure that staffing levels meet the assessed needs of residents. It is recommended that the home implements a vocational training programme to provide its staff team with the required vocational qualifications. It is recommended that the home develop a system for cascading training and information down to all relevant staff. It is recommended that the home produce annual development plan based on the results of the quality assurance system. It is recommended that all monies spent on behalf of a resident, for example group social trip are receipted or signed for by the resident. 3. OP9 4. OP27 5. 6. 7. 8. OP28 OP30 OP33 OP35 Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Morris Feinmann House DS0000021565.V326887.R01.S.doc Version 5.2 Page 30 - 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. 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