Inspection on 17/04/07 for Royal Manor

This inspection was carried out on 17th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Royal Manor 21/04/08

Royal Manor 25/04/06

Royal Manor 09/01/06

Royal Manor 17/03/05

Royal Manor 31/08/04

Royal Manor 03/02/04

Royal Manor 21/11/02

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Royal Manor 346 Uttoxeter New Road Derby Derbyshire DE22 3HS Lead Inspector Helen Macukiewicz Key Unannounced Inspection 17th April 2007 09:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Royal Manor DS0000002155.V334307.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. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Royal Manor Address 346 Uttoxeter New Road Derby Derbyshire DE22 3HS 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) 01332 340100 Mr N Beech Mrs Sandra Beech Mrs Sandra Beech Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2006 Brief Description of the Service: Royal Manor Care Home is a 25-bedded care home that provides both nursing and personal care, and is located in a residential area close to the centre of Derby. The property was originally a private dwelling that has been converted and extended into a care home. Residents’ bedrooms are located across 2 floors. All floors can be accessed via a passenger shaft lift or staircase. Eight single rooms and one shared room have en suite facilities. Communal areas are bright and decorated to a good standard. There are a number of lounges and one dining area. Royal Manor operates a no smoking policy for both Residents and staff. There is a large garden area to the front and side of the property. Residents can easily access the garden area. The current range of fees is between £310 and £478 per week, the Manager in the pre-inspection information provided this information. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and lasted 7.5 hours over 1 day. Prior to this, feedback had been sought from people who live at the home through questionnaires, of which 3 were received prior to the date of this visit. The Manager had provided written information about the home and this was used in the planning of this inspection. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were also referred to in the planning of this visit. During this Inspection discussion with residents and a relative took place. Time was spent in discussion with the Manager and staff. Three residents care files were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of some areas of the home took place. The last main inspection of this service occurred on 25th April 2006. However, a further inspection visit was undertaken on 14th December 2006 to follow up on requirements made in April 2006. The report produced as a result of the Inspection on 14th December was not made public, but should be available from Royal Manor, by request. The issues raised by the December 14th report have been considered in the planning of this visit, and this report may make reference to that visit if needed. What the service does well: Comments from a relative in a pre-inspection questionnaire stated ‘ it is reassuring to know that he (my relative) is receiving a high standard of care and attention appropriate to his condition and needs’. Residents are satisfied with the care and attention they receive, their comments included ‘I’m quite happy here’, ‘I settled in straight away’ and ‘the staff are the best thing about this home’. Staff receive over and above the required minimum amount of training and all but 2 care staff are qualified to at least NVQ 2 standard. The Matron provides a good level of supervision to the qualified staff. Provision of health care is good and there is a lot of liaison between registered nurses and health professionals in the community and hospitals to ensure that residents get the best care possible. One visitor said that they had noted improvements in the health ‘of their relative since being admitted to the home. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 does not apply; the home does not offer intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are given adequate information about the home to ensure that they are admitted appropriately and that their needs can be met. EVIDENCE: Residents said that they had enough information about the home before they moved in. All residents who were asked, said that a relative had arranged their admission and that they had the chance to visit the home before moving in. None of the four residents who were asked could remember being given any written information about the home but felt this was not necessary. Two residents confirmed that their experience of the home so far had met their Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 9 expectations on admission. One relative and a resident said that the Matron had given a good verbal explanation of what services the home could provide. The Matron confirmed that the written information about the home, designed specifically for residents (the service user guide) had been misplaced but intended to re-print further copies as this is stored electronically. The service user guide was also not in use at the time of the Inspection on 14th December 2006. This is an area where the Registered Providers have not made progress. The Matron verbally confirmed that she visits all prospective residents to undertake a needs assessment prior to their admission. She also confirmed that she has a discussion with the placing authority to ensure that the resident’s needs can be met by the home. The Matron was able to provide a blank assessment form that she uses to record this information on. In the care records examined for 3 recently admitted residents, only 1 had a completed needs assessment form in. Where completed, this was a comprehensive document and provided a good level of information about the person’s needs and preferences. However, for the other two residents, a combination of the absence of a needs assessment form and incomplete admission assessments meant there was very little written information about them. This would be useful for the staff to ensure care and facilities meet resident’s personal needs and choices. Despite this lack of documentation, residents and a relative who were asked said that the home did meet their individual needs and choices. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Residents have their health needs met in a respectful and dignified way although gaps in care planning and management of medicines means their well being is not fully safeguarded. EVIDENCE: Three resident’s care files were examined in detail and all contained a plan of care with some updates. Registered nurses had regularly reviewed all these plans. Care needs that had been identified tended to be focused on clinical needs rather than social, spiritual and psychological needs. In one care file the pre-admission assessment undertaken by a nurse assessor had identified that one of the aims of the placement in Royal Manor was to observe for signs of depression. This was not included in the Home’s care plan so was a need that could be potentially overlooked. In all three care files, the resident’s had recently been prescribed antibiotics but there had been no updates to the care Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 11 plans to reflect this change in needs, or direct staff in terms of the care the person required. There was plenty of evidence to support liaison with clinical and medical professionals working both in the community and local hospitals. Memo’s, diary entries and records in care files, along with information displayed in the office all supported that staff regularly make contact with these people for advice, support and training. Also that residents receive visits from the chiropodist, dentist and optician. One resident said that someone had been ‘to do his feet’, that he had received a hair cut and also had new glasses since his admission to the home. Around the home there was plenty of nursing equipment in use such as specialist beds, hoist slings, baths and chair cushions. In care files, regular reviews of people’s weight, skin condition and nutritional status were recorded. As were any risks associated with falls or moving and handling. There was evidence that relatives had signed consent forms for use of some nursing equipment. The Matron said that residents could look at their care files anytime, and these were stored in an accessible area. However, there was no evidence to support that residents/relatives had been involved in the formulating of the care plan and residents or their relatives had signed none to confirm that this had taken place. This was also a requirement for the Inspection dated 14th December 2007. The medication administration records (MAR) were briefly examined. These were generally well completed although not all administration of medicines had been signed for. In some places where it is necessary to use a code if medication had not been given, not all staff had written a code. On one sheet a medication had been written up twice which could lead to medication error. One resident who was self –administering a medication had not had a riskassessment completed for this, to determine their capabilities and consent. This was not recorded in their plan of care. However, the resident did have safe storage for the medication in their bedroom. All residents who were consulted said that they get enough privacy in the home; two confirmed that staff routinely knock on their bedroom door to request permission to enter. One resident confirmed that their privacy and dignity is upheld when being assisted to bathe. All residents consulted said that they choose what they wear in a morning if they need help from staff to dress. One resident said ‘ I get spoken to with respect’. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Social, cultural and recreational activities meet resident’s expectations although better care records would ensure all residents’ maintain an individual lifestyle of their choosing. Residents receive a healthy well balanced diet. EVIDENCE: Residents felt that within their physical limitations, they have the opportunity to pursue their own interests. Comments from residents were positive, such as ‘I can more or less do as I please in my own room’, ‘I have regular visitors and I go out with my relatives’. Also, ‘I have a mobile phone and a T.V. in my room and I do my crosswords – there is enough to do, in the summer I will go into the garden’. Visitors were coming and going throughout the inspection, although there is limited visiting during the early afternoon to enable staff to assist residents with their lunch in an unhurried way. Because most of the residents have a high level of physical disability, entertainers are brought into the home and a fashion show is also organised Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 13 from time to time. One resident confirmed that entertainers visit but said that they would like more to do in the home. The Matron recorded that entertainment had recently been organised. Some of the care records contained a family history/social interests sheet where details of personal preferences were recorded; one care record did not. Care plans did not cover social or spirituals needs and did not always record the religious persuasion of the person. Where residents are able to exercise a degree of control over their lives, the findings of this visit were that lack of records does not appear to affect their care. However, where residents are unable to express themselves verbally and have a high level of disability, staff would need to rely more heavily upon the records of what the person’s social and spiritual needs are, to ensure needs are met. Residents felt that they have control and choice over their day to day life. Comments included ‘ I get up and go to bed when I want’, ‘if staff come to help and I’m not ready to get up, they come back later’. One resident confirmed that they had a bath at their preferred time. One comment received was that ‘the night staff are very good to me, if I want a cup of tea at 3am I can have one’. Resident’s rooms appeared personalised with their belongings and most of the rooms visited had a T.V. in, which a relative said people bring in from home. Family pictures were displayed. Residents were satisfied with meals stating that ‘the meals are quite adequate’ and ‘the food is sufficient for me’. Residents said that there is a range of food offered and raised no concerns about the quality of meals. A visit to the kitchen was made, food stocks were sufficient and the cook had a sound knowledge of the dietary needs of residents. The menu was varied and the cook described ways in which he tries to encourage healthy eating. The kitchen was clean and tidy and catering staff were suitably qualified. Staff were observed to be assisting resident’s with their meals. Drinks were given out throughout the day. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s rights to complain are upheld and they are protected from abuse, although poor documentation and gaps in training means there is potential for error in the management of both. EVIDENCE: There were two complaints recorded since the last inspection. Both had been dealt with swiftly and resolved satisfactorily. The Matron confirmed that she is notified of all complaints and that the home has become more vigilant in acknowledging and recording minor issues as complaints. All residents said that they could speak to the staff and Matron if they had any problems and felt confident that things would be sorted out. A relative who was visiting shared this view. Residents couldn’t remember being given any written information about the complaints procedure and did not know how to contact the Commission for Social Care Inspection. One member of staff was happy with the internal system for complaints, but was not sure who to contact outside the organisation. A ‘whistleblowing’ policy was contained within the policy file. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 15 No complaints procedure was on display in the home although the Matron did provide a copy of the internal complaints procedures from a policy file, which appeared satisfactory. For resident’s, their version of the complaints procedures was not available on the day of the Inspection as the ‘Service Users Guide’, which would normally contain this information was missing. There had been one adult protection issue since the last Inspection. There was mention of this in the person’s care file. Both the Manager and member of staff who was aware of the incident confirmed that social services had been notified and were involved. There were no comprehensive records of what processes were followed in this case and the care plan did not contain any advice following this incident, to guide staff on how to maintain the protection of the person. However, staff were verbally able to describe their safeguards. There were Derby City and Derbyshire County adult protection procedures in the office and care staff said they had received training from external sources in adult protection. The internal procedures could not be located and one member of staff was unaware of what internal processes to follow if they witnessed an event. The cook and laundry personnel had not attended adult protection training. There was a restraint policy in the home and consent documentation was in place for use of equipment such as cot sides. Protection was provided for cot sides in use on beds for resident’s safety. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 physical layout of the Home enables residents to live in a comfortable environment, which is clean and generally well maintained. EVIDENCE: Areas of the building that were seen appeared well maintained. Bedrooms were subject to a rolling programme of redecoration and one resident said that they had moved bedrooms to one that had recently been painted. The gardens had become slightly overgrown but the Matron was aware that they needed attention and confirmed that this was going to be done soon. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 17 A fire risk assessment had been carried out and documentation was available to see, the home had a copy of their most recent environmental health officer’s report and the Matron was aware of any action points. The Home was clean and tidy and carpet cleaning was being undertaken during the visit. One resident said that ‘the home is very clean’. The laundry facility was seen; there was a newly appointed laundry staff who was present for this Inspection. There was sufficient laundry equipment and the member of staff had received training on personal hygiene and laundry duties. Washing machines allowed for a sluice cycle although it was evident that soiled items were not being washed at the correct temperatures, this was brought to the attention of the Matron who confirmed she would action this. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by competent, well trained staff although gaps in the recruitment of staff mean that resident’s welfare is not fully safeguarded. EVIDENCE: There was a staffing rota in place and sufficient numbers of staff; both care and ancillary were present during the day. Residents said there was always staff about if needed. The home has an excellent training record, which remains unchanged. All but two of the care staff are qualified to National Vocational Qualification (NVQ) level 2. Ancillary staff are also encouraged to further their education. Care staff were able to confirm the amount of training they have received and there was certificated evidence to support this. Three staff files were seen to check recruitment processes. New application forms had been put into place to assist in ensuring tighter recruitment procedures. However, the recruitment of staff contained some gaps, which if left unattended, could lead residents to be put at risk. The following information was missing from files:Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 19 • • • • • Declaration by the employee of any criminal offences was not in one file. Two files contained only 1 written reference and no notes about any discussions concerning verbal references sought. In two files there was no verification of the reasons why the person had left employment when working with vulnerable adults or children. Full employment history, including dates of commencing/leaving employment was not recorded in all three files. Criminal records bureau checks by the current employer were missing from all three files although there were previous CRB clearance forms from former employers. One file did not contain a statement by the person about their mental and physical health. One qualified nurse had not completed an application form. There was no record of any interviews that took place. • • • The Matron did not have documentation to support the level of induction training staff receive but staff did confirm that they had received an induction and that the Matron observes them performing tasks. Staff had also been assigned a ‘mentor’ when they first started, who was a more experienced member of staff. Staff are expected to commence NVQ’s within their first six months of appointment. New staff said they felt fully supported by the home, which helps to ensure the well being of resident’s is maintained during changes in staffing. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is adequately managed on a day to day basis although more effective internal quality assurance would support resident’s best interests are upheld. Health and safety hazards create unnecessary risks to the welfare of residents. EVIDENCE: The Matron in charge of the home is also the Registered Provider. She is a registered nurse and confirmed that she has attended periodic training updates in subjects relevant to her sphere of practice. She has not yet completed a Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 21 management qualification due to a change in circumstances in the management of the home. However, she has been managing care services for many years. The Matron is aware of the need to develop internal quality assurance within the Home. This was a requirement of the Inspection dated 14th December 2006, that has not yet been met by the Registered Providers. A new satisfaction survey has been devised and a copy was sent to the Commission for Social Care Inspection with pre-inspection information. This has yet to be implemented. A food survey had also been developed but again, this was yet to be implemented. There was no annual business plan for the home available, although the Matron said that this was under review. The pre-inspection information confirmed that the homes’ policies and procedures are reviewed periodically. Some of the policies were missing on the day of this inspection. There was no quality assurance policy, discharge policy, staff/residents access to files policy, or policy covering sexuality and relationships including same sex relationships and recognition of civil partnerships. The Matron had kept copies of ‘thank you’ cards and two were seen that had been received since the last Inspection. These contained favourable feedback. However, there were no formal systems in place for gaining feedback from relatives, friends and stakeholders within the community. The Matron had ensured that residents and relatives were given the opportunity to complete service user surveys sent out by the Commission for Social Care Inspection prior to this visit. The Matron confirmed that she only deals with the personal finances of 1 resident. This was formally agreed between the resident, Matron and the resident’s legal advisor. The resident said they were satisfied with the arrangements for the management of their money. The Matron confirmed that purchases made on behalf of the resident are all receipted. Most staff attended a risk appreciation course recently. There were risk assessments in resident’s files covering areas such a slips, trips and falls and related policies were seen. Maintenance records were sampled, those seen were up to date. The preinspection information sent by the Matron confirmed all equipment is regularly serviced and maintained. Although a full audit of the environment had not been undertaken and documented, specific areas of risk had been highlighted and action taken to make areas safe. A couple of risks were noted that require a risk assessment, the ground floor bathroom had a chute bolt lock on the inside of the door but access could not be gained from outside in case of emergency; a residents bedroom carpet was uneven which could cause a trip hazard. Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 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 2 17 X 18 2 3 X X X X X x 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 2 Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement A Service User Guide must be available for resident’s to ensure they have sufficient information about the home to maintain their rights in areas such as complaints and the right to information about the home. This item was to have been met by 20 June 2006 and again, by 8 February 2007. All changes to care needs must be updated in the resident’s plan of care to ensure that staff know how to maintain the welfare of residents. Timescale for action 30/06/07 2. OP7 15(2)(b) 30/06/07 3. OP7 15(1) and 15(2)(d) The Registered Provider/Manager 30/06/07 must ensure that each Resident, or their representative, has had the opportunity to discuss their personal preferences, choices, freedom and decision-making while staying in the Home. The outcome must be recorded in each Resident’s records. This item was to have been met by 20 June 2006 and again by 8 DS0000002155.V334307.R01.S.doc Version 5.2 Page 24 Royal Manor 4. OP9 13(2) February 2007. All administered medications must be signed for, or a recognised code used as to the reason why medication was omitted. Residents who are selfadministering must have written consent and a risk assessment in place. Prescribed medications must be correctly written up on the MAR sheet and not duplicated. This is to ensure medication errors do not occur thus upholding the safety and wellbeing of residents. All residents must receive a copy of the complaints procedure in a format that is suitable, to ensure they are fully aware of their rights in this area. Adult protection issues must be documented fully in care plans along with any necessary follow up actions to ensure safety of residents. Staff must be fully trained on internal adult protection procedures and a policy must be in place for them to follow to ensure safety of residents. CRB checks on staff must be carried out prior to appointment to ensure residents are safeguarded. 30/06/07 5. OP16 22(5)(6) and (7)(a)(b) 13(6) 30/06/07 6. OP18 30/06/07 7. OP29 19 (1) (5) and Schedule 2 30/06/07 8. OP33 24 Recruitment checks on staff must be consistent with the requirements of Regulation 19 and schedule 2. The Registered Provider/Manager 31/07/07 must address the issues listed within Standard 33.1 to 33.6. DS0000002155.V334307.R01.S.doc Version 5.2 Page 25 Royal Manor 9. OP38 13(4)(c) This item was to have been met by 2002 and again by 28 February 2007. The Registered Provider/Manager 30/06/07 must provide risk assessments on the environment including the areas where carpets are uneven and the bathroom where access cannot be gained in case of emergency to ensure safety of residents. 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. Refer to Standard OP3 OP16 OP26 Good Practice Recommendations A completed needs assessment should be maintained in the resident’s file for staff to reference to ensure staff are fully aware of the individual needs of residents. Staff should be given refresher training on the whistleblowing policy to ensure openness within the organisation. Laundry staff should receive further instructions regarding correct temperature for washing of soiled items to prevent spread of infection to resident’s. The Matron should undertake a registered managers award or similar management qualification. Relevant policies covering quality assurance, discharge of residents, staff/residents access to files, sexuality and relationships including same sex relationships and recognition of civil partnerships should be implemented and staff trained on these. OP31 OP33 Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Royal Manor DS0000002155.V334307.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!