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Inspection on 09/12/08 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 9th December 2008.

CSCI found this care home to be providing an Adequate service.

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

People are assured that their needs will be assessed and that staff can meet these before they make a decision to move into the care home. People using the service are supported and enable to live a full and active life of their choosing whilst maintaining contacts with people that are important to them. People using the service are protected from abuse and are assured that their complaints will be listened to and resolved. People live in a well maintained environment, which is comfortable and homely. The gardens are well kept and attractive. People using the service are supported by sufficient numbers of staff who have been recruited safely. Staff and people using the service talk freely and maintain positive relationships. People using the service are enabled to express their views and opinions about the care and support that they receive and be assured that these will be listened to and acted upon. People using the service tell us that they are settled and happy living at the care home.

What has improved since the last inspection?

New plans of care and key working has been introduced so that people using the service has a say in how their care is delivered. People using the service are included in the development of their care plans and all aspects of their care and daily living. The routine of the care home has become more flexible since the new acting manager started working at the care home. People now have more say in when they get up in the mornings and what time they eat their breakfast. Activities have continued to develop so that there are more available for people join in if they wish. Staff recruitment procedures have improved; all staff employed now undertake the necessary checks required by law to make sure that people using the service are protected from unsuitable people being employed. A number of carpets have been replaced and ongoing redecoration takes place to make sure that people live in a well maintained environment. Month audits are carried out to make sure that standards are maintained.

What the care home could do better:

Plans of care must be in place for people`s highlighted needs. This will ensure that staff have sufficient information to support people appropriately and ensure that peoples needs are fully met. Risk assessments and management plans must be in place for all highlighted risks. This will ensure that risks are managed and reduced as far as practicable and people remain safe. It must be ensured that no person using the service is subject to physical restraint unless restraint of the kind employed is the only practical means ofsecuring the welfare of that or any other person and there are exceptional circumstances. This will ensure that a person`s rights are maintained and they are not subject to abuse. All medication administered must be signed for as given. This will ensure that people receive their medication as prescribed.

CARE HOMES FOR OLDER PEOPLE Radcliffe Manor House Care Home 52 Main Road Radcliffe On Trent Nottingham NG12 2AA Lead Inspector Karmon Hawley Unannounced Inspection 9th December 2008 09:00 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.V373501.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.V373501.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 radcliffe.manor@virgin.net The Trustees of Radcliffe Manor House Vacant 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.V373501.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th November 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. The current weekly fees for the service range from £375 to £475, some top up fees may also apply and these are discussed at the point of enquiry. These fees dot include the cost of personal toiletries, newspapers, hairdressing and chiropody. Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for people who live at the home and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. We have introduced a new way of working with owners and acting managers. We ask them to fill in a questionnaire about how well their service provides for the needs of the people who live there and how they can and intend to improve their service. We received this back from the acting manager in good time and the form was well completed and helped us to plan our visit and to decide what areas to look at. We also reviewed all of the information we have received about the home since we last visited and we considered this in planning the visit and deciding what areas to look at. The main method of inspection we use is called ‘case tracking’ which involves us choosing four people who live at the service and looking at the quality of the care they receive by reading their records and asking staff about their needs. We were joined by an Expert by Experience who is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. Experts by experience do not need to have experienced an identical service. What matters is that they know what it is like to need a service. The expert by experience visited the home for three hours and spoke with six people using the service and one visitor. We also spoke with the acting manager, three members of staff, and three people using the service to assist us in forming an opinion about the quality of the service being provided to people living at the home. We read documents as part of this visit and medication was inspected to form an opinion about the health and safety of people who live at the service. What the service does well: Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 6 People are assured that their needs will be assessed and that staff can meet these before they make a decision to move into the care home. People using the service are supported and enable to live a full and active life of their choosing whilst maintaining contacts with people that are important to them. People using the service are protected from abuse and are assured that their complaints will be listened to and resolved. People live in a well maintained environment, which is comfortable and homely. The gardens are well kept and attractive. People using the service are supported by sufficient numbers of staff who have been recruited safely. Staff and people using the service talk freely and maintain positive relationships. People using the service are enabled to express their views and opinions about the care and support that they receive and be assured that these will be listened to and acted upon. People using the service tell us that they are settled and happy living at the care home. What has improved since the last inspection? What they could do better: Plans of care must be in place for people’s highlighted needs. This will ensure that staff have sufficient information to support people appropriately and ensure that peoples needs are fully met. Risk assessments and management plans must be in place for all highlighted risks. This will ensure that risks are managed and reduced as far as practicable and people remain safe. It must be ensured that no person using the service is subject to physical restraint unless restraint of the kind employed is the only practical means of Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 7 securing the welfare of that or any other person and there are exceptional circumstances. This will ensure that a person’s rights are maintained and they are not subject to abuse. All medication administered must be signed for as given. This will ensure that people receive their medication as prescribed. 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.V373501.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.V373501.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are assured that their needs will be assessed and that staff can meet these before they make a decision to move into the care home. The service does not offer intermediate care. EVIDENCE: The manager assesses people within the community when at all possible before admission to make sure that staff are able to meet their needs. There is evidence of this assessment taking place within the case files that we examined. So that people have an idea what it would be like to live at the home they can come to visit the care home and spend some time there before they make a decision to move in. Staff spoken with stated that they are informed of the needs of new people before they move into the home so that they can support them appropriately. Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 10 The service does not offer intermediate care. Radcliffe Manor House Care Home DS0000008736.V373501.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 adequate. This judgement has been made using available evidence including a visit to this service. As plans of care are not in place for all people’s highlighted needs, these may not be fully met. Due to the lack of risk management plans people may not be fully protected from highlighted risks. EVIDENCE: To make sure that staff are aware of people’s personal needs and preferences they undergo various assessments, however information gained is not fully utilised within plans of care, as these are mainly task focussed. Plans of care are not in place for all identified needs, such as diabetes mellitus and where a person may need the use of restraint due to behaviour that is challenging. There is no specific plan of care outlining when and how restraint should be used, to ensure that the person’s rights are protected and that they do not come to any harm. Staff spoken with outlined when they use restraint and how they do this, however there is no clear guidance within a plan of care available to ensure that all staff follow good practice recommendations. Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 12 Daily records are maintained and these contain some in depth information, however this information is not always utilised within the plan of care to make sure that these are up to date. Although risk assessments are in place for a number of risks, they are not in place for all highlighted risks to ensure that these are managed and reduced as far as practicable. There has been an incident where a person has wandered to the top of the stairs and staff expressed concerns about their safety, however this had not been followed up and no risk management plan put into place to ensure that this person remains safe should this reoccur. Also where a person is experiencing behaviour that is challenging, there are no risk assessments in place to outline how staff support them and others to reduce the risk and make sure that everyone remains safe from harm. People using the service told us that staff are kind and caring and that they looked after them well. Staff spoken with are able to discuss the individual needs and preferences of people using the service and how they support them in meeting these. The manager stated that good relationships are maintained with the district nurses and general practitioners. During our visit the district nurse came into the care home to attended to a person living there, we saw that good relationships are maintained. During our tour of the care home we saw that people have access to specialist equipment such as special beds and cushions. On examining people’s plans of care we saw that they are supported to access specialist services such as the doctor when they need to. One person spoken with said that although they are in good health, they can see the doctor if they needed to and the staff would arrange this. Another person told us how they are helped to move by the staff and that they have a special cushion to sit on, which is very comfortable. Staff who administered medication have been trained to do so to make sure that they are aware of good practices. The medication practices examined show us that although people are receiving tablets as prescribed there are gaps in staff signing for liquid medication, creams and eye drops to show that they have received these as prescribed. The manager is aware of this following an audit and a memo has been posted for staff to address these issues. One person using the service spoken with told us, ‘staff give me painkillers when I need them as I often get pain.’ Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 13 People using the service told us that they are treated with respect and their dignity is upheld, however one person objected to being called blossom, dear or other silly names. This was discussed with the manager who stated that she would address this issue with staff. Staff spoken with are able to discuss how they maintain people’s dignity by way of their working practices, such as knocking on doors and covering people up when supporting them with personal care. During our visit we saw staff treat people using the service with respect. Radcliffe Manor House Care Home DS0000008736.V373501.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are supported and enable to live a full and active life of their choosing whilst maintaining contacts with people that are important to them. EVIDENCE: There are several members of staff employed to support people with activities five days a week. Activities on offer are variable and sometimes depend on the time of the year. At present people are busy with a Christmas theme and have been making cards and decorations. Other activities such as bingo, quizzes, music to movement and games are on offer. Some people go to the village, to the local church or visit the local Women’s Institute or British Legion as they wish. Staff spoken with feel that there is enough for people to do throughout the day. People using the service told us that they enjoy the activities on offer, however two people expressed a wish for more intellectually challenging games. The activities coordinator on the day of the visit had a good rapport with people using the service, as did all the staff on duty. We saw people using the Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 15 service talk freely and comfortably with staff, who responded in a relaxed way. There is a relaxed atmosphere in the care home and all people spoken with said that they feel happy, secure and settled within the care home. One visitor, in speaking about his mother, said that, ‘she is looked after well and the staff relate to her well.’ He hoped that she could remain in the home as he and his family are pleased with the care provided. There are no restrictions on visiting so that people using the service can maintain contacts with people that are important to them. Visitors may be received in private and there is a quiet room available for use. Staff spoken with confirmed that visitors are always made welcome and that they can come at any time. One person using the service told us that their family come regularly and that they are made very welcome. People using the service are registered for postal votes, which they can choose to use or not. Information on advocacy services is on display on the ‘residents’ notice board should this service be required. Staff spoken with stated that they felt that people using the service are treated as individuals and that their rights and choices are maintained at all times. They spoke of people’s differing personalities and the way individuals preferred their care, demonstrating a good understanding of people using the service. All people using the service spoken with told us that the routine is flexible and they can make their own choices about when they get up and go to bed, what they wear and how they spend their time during the day. There are no concerns about the possibility of a presence of any ridgity of routine. A wholesome and appealing menu is on offer for people using the service and specialist diets such as diabetic diets are catered for. The meal on the day of the visit was nicely presented and was plentiful. People using the service stated that they are quite happy with the quality of the food and that they could have a choice if they wanted, however another felt that there could be more choices available for special diets. Staff spoken with told us that the food served is of a good quality and confirmed that specialist diets are catered for. They also stated that drinks and snacks are available at any time during the day if people wanted them. Radcliffe Manor House Care Home DS0000008736.V373501.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are protected from abuse and are assured that their complaints will be listened to and resolved. EVIDENCE: So that people can make a complaint if they want to, they are given a copy of the complaints policy when they come into the care home. A copy of this is also on display in the home for people to access. The service has received a number of complaints since the previous inspection in regard to the standard of care and facilities. There is evidence within the complaints folder that all of these issues have been fully investigated and resolve appropriately. Staff spoken with are able to discuss how they would deal with a complaint should one be received so that this may be resolved. People using the service told us that staff listen to them, with the exception, that on a few occasions when they are busy and they are unable to stop to listen to them. One person using the service told us that they knew who they could make a complaint to if they are unhappy, however they are in fact happy and settled living in the care home. Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 17 There has been one safeguarding issue referred to the Local Authority in regard to an allegation of bruising. This issue was investigated and resolved appropriately. Staff continue to undertake training in safeguarding adults and when spoken with they are aware of their roles and responsibilities in keeping people safe and protecting them from abuse. Radcliffe Manor House Care Home DS0000008736.V373501.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. People live in a well maintained environment, which is comfortable and homely. EVIDENCE: The home is a large, extended house with several small well kept gardens over looked by most of the people using the service. There are various seating areas around the care home that people can access should they wish. There is evidence of ongoing maintenance taking place and the care home is generally well maintained. Some new carpets have been put in people’s rooms and there is a programme of ongoing replacement of these to make sure a comfortable and pleasant environment is available. Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 19 All areas of the care home are clean and tidy, however one bedroom has an offensive odour present. The manager has had a cleaning representative visit the care home to try out a new product to address this issue. People’s room accessed with their permission during the tour of the care home are personalised with their own belongings. Radcliffe Manor House Care Home DS0000008736.V373501.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): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are supported by sufficient numbers of staff who have been recruited safely. EVIDENCE: The duty rota examined shows us that sufficient staff are available to support people using the service when needed. One resident said, people sometimes have to wait for assistance. There were no other negative comments received. Staff spoken with said, ‘the staff team work well together and help each other out, there are enough staff available to support people,’ and ‘ there are enough staff to help out, it can be a bit difficult if someone phones in sick, but we do manage.’ During our visit we saw staff helping people when needed and no one had to wait for long periods of time. To ensure that all new staff are aware of their roles and responsibilities when they commence employment they undertake an induction. There is evidence of new staff undertaking an induction within staff files examined. One new member of staff spoken with said that they had undertaken an induction when they first started working at the care home and it had been very useful in Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 21 helping them to get to know the routine of the home and the people living there. So that staff have the necessary knowledge and skills to support people using the service over 50 have undertaken the National Vocational Qualification (a nationally recognised work and theory based qualification), the remainder of the staff have been registered to commence this training. Two members of staff spoken with confirmed that they had undertaken this training and they felt that it is very useful and informative. To ensure that people using the service are protected from unsuitable people being employed staff undertake a Criminal Record Bureau check (a police check to see if an individual has a police caution or criminal record) before they start working at the home. We examined staff personnel files, which show us that criminal record bureau checks, and all other documentation required by law is in place. Staff spoken with confirmed that they undertook a Criminal Record Bureau check before they commenced working at the care home. Staff personnel files show us that staff continue to undertake compulsory training such as manual handling and fire safety. There is evidence that further training course have been booked to address any shortfalls. Staff spoken with told us that training is at a good standard and that they feel supported in their development. One person using the service told us that they feel that staff are well trained as they know how to look after them. Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 28 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are enabled to express their views and opinions about the care and support that they receive and be assured that these will be listened to and acted upon. EVIDENCE: The acting manager is not yet registered with the Commission for Social Care Inspection, however she stated that she is in the process of applying to become the registered manger. She has previous experience in health and social care and she has nearly finished the Registered Managers award (a nationally recognised work and theory based qualification designed to enhance management knowledge and skills.) Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 23 Staff spoken with stated that the management is very supportive at all times and available when needed; ‘the management are fantastic, brilliant, they are always there for you if you need them.’ One person using the service told us that they feel that the home is well run and managed and that they really like the manager who comes to speak to them quite often. People using the service are enabled to express their views and opinions about the service that they receive by way of annual questionnaires, care plan reviews and informal chats with staff. We saw that 50 of people had responded in the last questionnaire and positive comments such as ‘my father always appears to enjoy his food and he certainly doesn’t go hungry,’ ‘I have visited the dining room on a number of occasions and there is always a nice atmosphere,’ and ‘I think dad receives the attention he need,’ were received. There were a few negative comments, which the manager stated that she is currently acting upon to resolve. The manager carries out regular audits such as pressure area care, accidents and people’s weights to make sure that a quality service is maintained and any issues can be addressed immediately. Regular staff meetings also take place so that issues of maintaining good practice can be discussed. Staff spoken with confirmed that these take place and that they are useful. Plans of care outline the financial arrangment in place for keeping people’s fianancal interests protected. On examining these, accounts corresponded with the accounting sheet and recripts are availble for all transactions. Staff spoken with outlined th eprocedures that are in palce for accessing people’s money to make sure that it is protected. The annual quality assurance information sent to us before the inspection informed us that routine maintenance is taking place, to confirm this we examined the hoist and gas certificate during our visit. Some staff have undertaken training in health and safety and when spoken with they are able to discuss the relevant issues in regard to ensuring a safe environment is maintained for people using the service. Radcliffe Manor House Care Home DS0000008736.V373501.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 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 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Radcliffe Manor House Care Home DS0000008736.V373501.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 OP7 Regulation 15(1) Timescale for action Plans of care must be in place for 20/01/09 people’s highlighted needs. This will ensure that staff have sufficient information to support people appropriately and ensure that people’s needs are fully met. Risk assessments and 09/12/08 management plans must be in place for all highlighted risks. This will ensure that risks are managed and reduced as far as practicable and people remain safe. You must ensure that no person 10/01/09 using the service is subject to physical restraint unless restraint of the kind employed is the only practical means of securing the welfare of that or any other person and there are exceptional circumstances. This will ensure that a person’s rights are maintained and they are not subject to abuse. All medication administered must 20/01/09 be signed for as given. This will ensure that people receive their medication as prescribed. DS0000008736.V373501.R01.S.doc Version 5.2 Page 26 Requirement 2 OP7 13(4,c) 3 OP7 13(7) 4 OP9 13(2) Radcliffe Manor House Care Home 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 OP7 Good Practice Recommendations Develop plans of care to ensure that they become person centred and reflect people’s personal choices and preferences so that they receive care in their preferred way. Consult further with those people using the service who have requested more intellectual activities so that this can be facilitated. Consult further with people who have special diets to ensure that they are fully aware of the choices available to them. Maintain regular cleaning or renewal of carpets to keep the offensive odour at bay. 2 3 4 OP12 OP15 OP26 Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Radcliffe Manor House Care Home DS0000008736.V373501.R01.S.doc Version 5.2 Page 28 - 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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