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Inspection on 13/11/06 for Radcliffe Manor House Care Home

Also see our care home review for Radcliffe Manor House Care Home for more information

This inspection was carried out on 13th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents are properly assessed before going to the home, so they can be sure the staff can meet their needs. Health needs are properly assessed and provided for making sure residents are healthy. Residents are treated with dignity and respect and their choices are upheld. Activities are provided and families and friends are encouraged to maintain contact with residents so they do not get isolated. Meals are appetising, nutritious and varied to make sure the residents stay healthy and well. Residents know they can complain and they would be confident their concerns are taken seriously. Residents feel safe and protected from abuse. The home is homely, comfortable, warm, clean and well maintained. It provides a nice place for residents to live and they are happy there. There are enough staff to meet the needs of residents and they are well trained and competent. The residents, relatives and visiting professionals get to have their say about the care provided at the home. These views are made public and the manager tells residents what she will do to make things better. The arrangements for managing residents` money are safe and protect their interests.

What has improved since the last inspection?

The care plans have a new style which has led to some improvement in the information available to staff on how to help residents. Some of the staff have had training in understanding abuse. This helps them to protect the residents more effectively.

What the care home could do better:

The manager could make sure that all residents have a copy of the service user guide and that they understand it when they come into the home. All residents should have a contract with the home, so they are clear about how much they pay, and what this includes. The arrangements for giving residents their medication could be safer to make sure that residents get the medicines as prescribed by their GP. Meals could be blended separately so they look more appetising. The worn and old carpets in residents` bedrooms could do with replacing.The recruitment procedures could be better if the manager got all of the information needed to protect residents from abuse. Some health and safety checks are outstanding and this would make the home safer for residents and staff.

CARE HOMES FOR OLDER PEOPLE Radcliffe Manor House Care Home 52 Main Road Radcliffe On Trent Nottingham NG12 2AA Lead Inspector Linda Hirst Key Unannounced Inspection 13th November 2006 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 Radcliffe Manor House Care Home DS0000008736.V318884.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. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Radcliffe Manor House Care Home Address 52 Main Road Radcliffe On Trent Nottingham NG12 2AA 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) 0115 911 0138 The Trustees of Radcliffe Manor House Mrs Valerie Dixon Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Radcliffe Manor House Care Home, a voluntary organisation and registered charity is owned by the Trustees of Radcliffe Manor House. The home is located on the outskirts of the village of Radcliffe on Trent and local amenities and public transport links are a short walk away. The building is a converted and extended manor house, providing personal care and accommodation for up to 24 older people. All bedrooms are single, five having en-suite facilities. There is a passenger lift to the first floor, also a stair lift to aid access to the first floor in the annexe area. The home sits in it’s own private grounds and there is a car park to the side of the building. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven and a half daytime hours, including lunchtime. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and looking at the quality of the care they receive. Some of the people who live at this home have a limited ability to understand and communicate. Therefore some of the judgements in this report are from observation and reading residents’ records and documents. The residents who were “case tracked” were not able in some instances to give a detailed opinion about the care provided. One resident who could express opinions was spoken with. Unfortunately, no relatives were seen during this inspection. Two members of staff and the deputy manager were spoken to as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. No service user questionnaires were returned before the visit to the home, but the questionnaires completed by residents and relatives at the home were looked at to form an opinion about the quality of care. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk What the service does well: Residents are properly assessed before going to the home, so they can be sure the staff can meet their needs. Health needs are properly assessed and provided for making sure residents are healthy. Residents are treated with dignity and respect and their choices are upheld. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 6 Activities are provided and families and friends are encouraged to maintain contact with residents so they do not get isolated. Meals are appetising, nutritious and varied to make sure the residents stay healthy and well. Residents know they can complain and they would be confident their concerns are taken seriously. Residents feel safe and protected from abuse. The home is homely, comfortable, warm, clean and well maintained. It provides a nice place for residents to live and they are happy there. There are enough staff to meet the needs of residents and they are well trained and competent. The residents, relatives and visiting professionals get to have their say about the care provided at the home. These views are made public and the manager tells residents what she will do to make things better. The arrangements for managing residents’ money are safe and protect their interests. What has improved since the last inspection? What they could do better: The manager could make sure that all residents have a copy of the service user guide and that they understand it when they come into the home. All residents should have a contract with the home, so they are clear about how much they pay, and what this includes. The arrangements for giving residents their medication could be safer to make sure that residents get the medicines as prescribed by their GP. Meals could be blended separately so they look more appetising. The worn and old carpets in residents’ bedrooms could do with replacing. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 7 The recruitment procedures could be better if the manager got all of the information needed to protect residents from abuse. Some health and safety checks are outstanding and this would make the home safer for residents and staff. 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. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Privately funded residents do not have contracts in place to inform them of the cost of their care, what this includes and what they can expect the home to provide. Residents are assessed before admission to ensure that their needs can be met at the home. They are given time and support to settle in to their new home. EVIDENCE: The arrangements for admission were checked to make sure that residents are properly assessed before admission to avoid inappropriate placement. The manager or deputy assess all potential residents in their current setting, even if they have already been assessed by a Social Worker to check their needs can be met. Staff and one of the residents who was interviewed confirmed this. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 10 She said that when people are newly admitted the staff give them time with relatives before having a chat with them and showing them around. The arrangements help people settle at their own pace. All of the residents seen appeared happy and appropriately placed at the home. Intermediate care is not provided at the home and this standard is not applicable. This inspection was also a “thematic inspection.” This means that areas of National concern are identified and sample questions are asked of residents in homes across the Country to see how well services perform in key areas. The following answers were in response to thematic inspection questions. Do you have an up to date copy of the service user guide? One person said they had not received this, the other two people could not remember and said they did not know. There was no evidence of service user guides in the files of residents seen. It is recommended that a system be put in place to evidence that all residents or their relatives receive a service users guide to the home. Have you had any changes to the cost of your care? None of the three people interviewed could answer this question as their family members manage their money on their behalf. None of the families were at the home during this inspection. Do you have a written contract? None of the three people interviewed could answer this question as their family members deal with contracts and all financial matters on their behalf. None of the families were at the home during this inspection. However, all of the three residents fund their own care, and none of them had a contract and statement of terms and conditions on file. The registered person should ensure that all residents have a contract in place which covers the areas specified in Standard 2. Did anyone talk to you about your care needs before you came to live here? One person who was interviewed said this had happened (see above), the other two could not remember and said they did not know. There is evidence on each of their files that the manager or deputy properly assessed them before admission. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are detailed enough for staff to be clear about how to help residents with their needs. They reflect the current needs of residents. Health care assessment and provision is good and the residents get the help they need to remain well and healthy. Medication practice is not safe and action is needed to make sure that residents get the correct medication in a safe manner. Residents are treated with dignity and respect. EVIDENCE: Care plans were inspected for “case tracked” residents to ensure they cover all of their needs in enough detail to guide staff properly. The care plans have a new format and this is an improvement. They are basic, but adequate and the residents who were interviewed said they get all the help they need and that Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 12 staff are caring. Residents, relatives and visiting professionals did not raise any issues care in a recent quality assurance questionnaire. There is evidence of monthly reviews. One resident could not remember if he had a care plan, the other said she did, she knew what one was and knew she could see it if she chose to. She said that she does not choose to. Staff confirmed that care plans are in place and feel these are detailed enough to guide them. Service users said their health is well looked after, a GP is called if there are any concerns, if nurses are needed they are called in. They did not express any concerns about health care provision. One resident said she had regular appointments with the chiropodist, optician and dentist as needed. Another who is partially sighted said she gets good support from staff to find her way around the home. There is one designated GP for the home who will visit the home when required and relationships with her are reported by staff to be good. There is good written evidence that residents’ health is constantly monitored (monthly weight record, record of personal care, facial care and foot care and records of pressure area care.) The arrangements for medication were inspected to make sure that these are safe and that residents get their medicines as prescribed by their GP. Medication is stored in a locked trolley and this is kept in the office, secured to the wall. Controlled Drugs are kept in a separate locked cupboard. Controlled Drugs records were checked and countdowns tally with remaining tablets, indicating that these are handled with care. The returns book was seen, and the records were well maintained with evidence of the signature of the collecting pharmacist. The Medication Administration Records were well maintained with no omissions unaccounted for. The lunchtime medication was observed, it was noted that medication is left with some residents to take later. There are no risk assessments in place to indicate that this is safe practice, especially as some of the residents have Dementia and may take tablets inappropriately. The manager either has to change this practice or supply risk assessments to evidence that this is safe for all of the residents concerned. One member of staff said the manager on duty would sometimes give her medication to take to the residents if she is busy, but she does not sign the record. This is not acceptable; the person who witnesses the resident taking medication should sign to confirm that to the best of their knowledge it has been taken. Staff confirmed that they have had training on medication from Peoples College. The residents spoken with have their medication looked after by staff members. They said they bring the their tablets with water so they can take them and make sure they have done this before leaving. They had not seen anything unsafe. An immediate requirement was made about medication practice. Residents said staff treat them well, theyre nice people. They said they are treated with dignity and the staff are very discreet and helpful. They said that staff knock on doors before coming in, call them by their preferred name and make sure letters are not opened. They can see visitors in private, and as Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 13 there is a cordless phone at the home, they can take calls in private. The staff gave examples of how they ensure residents have privacy. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy regular activities and trips out to keep them occupied and stimulated. Residents are encouraged to maintain contact with family, friends and the local community to prevent isolation. Choices made by residents are recorded, respected and upheld. The food provided is varied, tasty and plentiful and ensures that residents’ health and wellbeing is maintained. EVIDENCE: On arrival at the home an activity was already underway with residents to occupy their time. An activity organiser is employed five days a week for three and a half hours and on the day of the inspection, BINGO and movement to movement activities were being provided. The activities provided are recorded in a book, these include; quoits, singing, board games, quizzes, sayings and Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 15 proverbs and the record indicates who has joined in. One resident said he likes to keep himself to himself and likes to sit out in the garden if the weather is nice. Another likes to join in activities if she likes them, such as BINGO and movement to music. She said regular activities are provided and that she can choose whether to take part, sometimes she does, other times not. She also goes out with her family. Staff confirmed that the residents enjoy the activities and join in, though one felt there could be more variety in the activities provided. They said they take some residents out “every week,” and birthdays are celebrated with a party tea. Residents said that their family and friends could visit whenever they wish, there are no visiting restrictions and they said the staff make all visitors’ welcome. One chooses to see her family in private and a quiet lounge is made available for this purpose. Staff confirmed that there are no visiting restrictions in place and that relatives are welcome to visit when they wish, or take residents out if they prefer. All of the residents are registered to vote using postal votes, which they can choose to use or not. One resident said that he is registered to vote though he couldnt remember if he had done so. The other did not know whether she was or not. Information on advocacy services is displayed on the residents notice board. Staff interviewed confirmed that residents have access to postal voting if they wish. Routines at the home are flexible and this was confirmed by residents and staff interviewed. The weekly menu is displayed on the residents notice board. The residents said that the food provided is good, with plenty of variety and they feel they get enough to eat and drink. They could not think of anything they specifically wanted on the menu. Lunch was observed. Residents sat in groups of four. A variety of drinks were provided with the meal. A main menu is provided, but two residents were having meatballs instead as they were Jewish. One person was vegetarian and dislikes soya products so fish was given as an alternative and different sauces and vegetables are used. There was one person who has a blended meal, this is done all together, it is recommended that food be blended separately to maintain appetite. Good stocks of food are kept at the home, there were plenty of tins and dried food, with fresh fruit and vegetables. Food safety practices were observed. Staff interviewed said that the food is good, with plenty of variety and they said snacks can be provided on request. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 19 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know they can complain and would feel confident that any concerns would be taken seriously and investigated. The residents are well protected at the home, but some staff would benefit from training on abuse issues. EVIDENCE: There is a complaints procedure at the home and this is displayed on the residents notice board to make sure they are aware of how to complain should they wish to do so. There have been no complaints to the home or to the Commission since the last inspection of the home. Residents said they could not remember whether they had received a complaints procedure. They said however that they would feel confident to make complaints, though one said she couldnt be bothered to unless it was serious. Then she would report it to the manager who she felt would sort it out. Staff who were interviewed understood the complaints procedure and the need to report all complaints to the manager. Neither had dealt with any complaints themselves. There have been no allegations of abuse since the last inspection, indicating that residents are well protected. The residents said they felt safe at the home (very much so,) and well cared for. They have never seen or experienced anything which worried them. One said she would report any inappropriate Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 17 treatment straight away. One staff member gave a good account of what constitutes abuse, and said she would report it straight away, though the other had only a limited understanding of abuse and what to do in the case of allegations being made. There is evidence that the manager, deputy and two members of staff have received training from Nottinghamshire Adult Protection Unit on abuse issues in July this year. The plan is to cascade this training to all staff at the home, it is recommended this be done as soon as possible. This area was also the subject of some thematic inspection questions. Have you had written information about how to complain? One resident said she hadn’t, the other two residents could not remember and said they did not know. Do you have the information you need to raise any complaints? Two of the residents interviewed said they did, one could not remember and said he did not know. Overall it would seem that although residents have not been given written information about how to complain, they are aware that they are able to and know how to do this. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, comfortable, homely and clean throughout offering a good standard of accommodation to residents. EVIDENCE: There are three lounges and one dining room at the home; all are comfortable, cosy and warm. A sample of bedrooms were seen and these are highly personalised as most of the residents fully furnish their rooms. Some of the decoration and carpeting in the bedrooms is looking worn and in need of replacement. This issue had been raised by a relative in the quality assurance questionnaires. There are adequate assisted bathing and toileting facilities available. The home is well maintained, clean and comfortable throughout. All of the residents said the home is kept clean and tidy and any repairs are done quickly. They like their bedrooms and two said they had fully furnished it, the other said he could not remember if he had his own things at the home. One Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 19 said she was extremely happy with the laundry arrangements and said it is done quickly and efficiently. The residents like the home and feel it is warm, comfortable and homely. Staff interviewed said that all repairs and redecoration issues are referred to the handyman and done quickly. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough staff to meet the needs of the residents. The recruitment procedures of the home are not robust enough to make sure that residents are fully protected from potential abuse. The staff are well trained and competent in their roles. EVIDENCE: The staff rota was inspected for this week to check that there are enough care staff on duty to meet the needs of residents. This indicates that there are three staff on day time shifts for most days. There are also good levels of ancillary staff employed to make sure the home is clean and the catering done. The staffing levels meet minimum requirements but also seem appropriate to the needs of residents and residents and staff confirmed this. Staff files were inspected to make sure that they contained all of the information and documents required by Law to protect residents. These raised concerns about Criminal Records Bureau checks, the references which were obtained, and the supervision of staff during induction. These matters were the subject of an urgent action letter. The staff who were interviewed were long serving staff members who could not reasonably comment on the procedures Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 21 for employing new staff. They confirmed they have had their Criminal Records Bureau checks returned. The records of individual training attended is recorded in staff files. The training file indicates that courses have been attended on Moving and Handling, First Aid, Incontinence, the safe management of medicines, and Dementia training (delivered by Castle College). Basic Food Hygiene and Infection Control training have also been done done. Staff confirmed the training they have received matched the home records. Residents said the staff are very nice and helpful. They said they get on well with the staff and the staff seem very good at their jobs and know what they are doing. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality assurance questionnaires are used to make sure that the home is being run in the best interests of residents. The arrangements for managing residents’ finances are safe and protect their financial interests. Health and Safety is generally well managed to make sure the home is safe for residents and staff. EVIDENCE: Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 23 The registered manager was not on duty so it was not possible to evidence her qualifications. The staff and residents who were interviewed said that the home was well managed. The staff commented that the manager is, approachable,, takes staff comments on board, and is, lovely and easy going. A quality assurance questionnaire has been conducted using questionnaires sent out to residents, relatives and visiting professionals, this was dated 14/8/06. The outcomes have not yet been collated but the questionnaires were inspected. The issues raised were about activities (the variety), re decoration of rooms and replacement of carpets. There were compliments about the extras provided at the home to make residents’ lives better, including flowers, wine, gifts at Easter, singers at Christmas. Staff were said to be “welcoming and accommodating. One relative commented, We feel confident that staff are kind and caring and respect individuals needs and wishes, she is supported with sensitivity as her memory diminishes.Another commented on a great bunch of staff. I have nothing but praise for the standard of care provided. Visiting professional commented lovely home, well kept with lots of laughter.I cant think of any improvements. The staff are extremely friendly and always very helpful. There was no indication that an action plan has been done in response to the issues raised yet, but there is evidence that this was done last year as this is still displayed on the notice board. The arrangements for residents’ finances were inspected to maked sure their financial interests are properly protected. Good records of expenditure are maintained and receipts are kept. Thease arrangements were confirmed in staff interviews. One resident has quite a lot of money in the home, much of this has now been transferred to a client investment account by Social Services. The amounts held at the home for each individual tally with the records kept and demonstrate that careful checks are maintained on residents’ money. The residents confirmed that their money is held securely and they can access it without difficulty. Health and Safety information was inspected. The gas boiler servicing has not been done, but there is a contract in place for this which was seen. The deputy rang in my presence on the day of the inspection and arranged for this to be done. Emergency Lighting tests were last recorded in July this year and these should be done once a month, although all other fire safety tests have been done as required. The registered person should send evidence to confirm these two matters have been attended to. All other Health and Safety tests and services have been done on time and by appropriately qualified people. The home is safe for residents and staff to live and work in. Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 24 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement The registered person must ensure there is a system in place for the safe receipt, recording, administration and disposal of medication. Immediate Staff files must comply with Schedule 2 of the Regulations. Urgent Action. Timescale for action 13/11/06 2. OP29 19, Sch 2 24/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP1 OP2 OP15 OP18 OP19 OP38 Good Practice Recommendations A system should be put in place to make sure that all residents have a copy of the service user guide. ALL residents should be issued with contracts covering the areas specified in Standard 2. Food should be blended separately to maintain appetite. The registered person should appoint someone to cascade the NCPVA training undertaken to all staff. Worn carpets should be replaced. Evidence should be sent of the servicing of the gas boiler and the monthly emergency lighting tests. DS0000008736.V318884.R01.S.doc Version 5.2 Page 26 Radcliffe Manor House Care Home Radcliffe Manor House Care Home DS0000008736.V318884.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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