Inspection on 21/04/08 for Royal Manor

This inspection was carried out on 21st April 2008.

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 17/04/07

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 Steve Smith Unannounced Inspection 21st April 2008 10:15 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.V362366.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.V362366.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.V362366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th April 2007 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 ensuite 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, and Residents can easily access the garden area. The charges made for a place at Royal Manor, at the time of this visit, ranged from £356.00 to £494.00 a week, dependent on whether the Resident has residential or nursing needs and the level of those needs. Details of previous inspection reports can be found on the Commission for Social Care Inspection’s website: www.csci.org.uk Royal Manor DS0000002155.V362366.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 people who use this service experience Adequate quality outcomes. This unannounced visit took place over a period of almost 6.5 hours. During the visit discussion was held with two Residents, one relative and one visitor, and the records of three Residents were ‘case tracked’. Discussion was also held with the Manager and with two members of the care staff. A number of the Home’s records were examined, all of the bedrooms in the Home were also examined, and all public areas of the Home were looked at. The Commission’s Annual Quality Assurance Assessment questionnaire, sent to the Manager, was examined. The Commission’s Residents questionnaire was sent to 5 Residents, although only 2 were returned, and to 5 relatives, but again only two were returned by the time of this visit. However, all commented most favourably about the Home. The Commission also sent out 10 questionnaires to staff and only one was returned at the time of this visit. What the service does well: What has improved since the last inspection? The administration of medication was found to be well maintained at the time of this visit. Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 6 People staying in the Home were found to receive a complaints procedure and Safeguarding Adults procedures were found to be in place, both of which were confirmed by staff spoken with. What they could do better: A fully completed Residents Guide was needed, which also needed to be distributed to all people staying in the Home. This is to ensure that people staying in the Home, and their relatives, are provided with all the details on the Home’s operation. This had been outstanding as a Requirement since April 2006. Improvements were also needed to the Resident’s Plans of Care. However, this had been begun in the Home, but had not at the time of this visit included all the Plans of Care of all people staying in the Home. This is needed to ensure that staff, and those staying in the Home or their representatives, are aware of all of the needs of those staying in the Home. Some of these issues had been outstanding as Requirements, again, since April 2006. A number of improvements were needed to the fabric and provisions made in the Home, to ensure that the Home provides a satisfactory standard for each person staying. When appointing new staff the Registered Provider/Manager needs to ensure that she meets all of the requirements of Schedule 2 of the Care Homes Regulations 2001. This is to ensure that only appropriate people are appointed to work with people staying in the Home. This has been outstanding since April 2007. The Registered Provider/Manager was found to have no adequate Quality Assurance measures operating in the Home. These are needed to ensure that the Registered Provider/Manager is meeting all the needs of those staying in the Home, as well as the needs of staff and the administrative needs of the Home. This Requirement had been outstanding since 2002. It was also found that the Registered Provider/Manager was not providing formal supervision for all care staff. This is needed to ensure that the Registered Provider/Manager is aware of the needs of her staff and of the people staying in the Home, and makes plans to meet those needs. It was found that a number of staff were in need of mandatory training in Moving and Handling, First Aid and Food Hygiene. This is needed to ensure that all staff have the knowledge to meet the needs of people staying in the Home, and to ensure that the Home is run to satisfactory standards. Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 7 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.V362366.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 Royal Manor DS0000002155.V362366.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): Standards 1, 2, 3 and 6. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. The Residents Guide lacked significant information, and so people staying in the Home were not appropriately informed of the operation of the Home. However, all new people moving to the Home were appropriately assessed prior to their admission, so that they and their families were reassured that their needs would be met. EVIDENCE: The Registered Provider/Manager had provided a detailed statement of purpose for the Home together with the Residents Guide, which informed people staying in the Home, and their relatives, of what the Home provided. However, the Residents Guide did not contain information, for people staying in the Home, describing the individual bedrooms and communal space provided, nor the relevant qualifications and experience of the Registered Provider/Manager or her staff. It also lacked information about the number of places provided and whether the Home could meet any special needs or Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 10 interests of people planning to stay in the Home. The Residents Guide also did not refer people staying in the Home to the location of the last Inspection Report provided by the Commission, and it did not provide any comments made by people staying in the Home on their views of their stay. The records of three Residents were examined during this visit and a copy of the statement of terms and conditions of residency or a contract, if purchasing their care privately, were available in the Home. This ensured that peoples legal rights were protected. When new Residents were admitted to the Home, the Registered Provider/Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. The Registered Provider/Manager also assessed all Residents sponsored by Social Services Depts. If the Residents were selffunding from the outset, the Registered Provider/Manager completed her own summary of needs, which were also seen during the inspection. Standard 6 does not apply to this Home. Royal Manor DS0000002155.V362366.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): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being appropriately met, as demonstrated within care plans, and medication was administered appropriately to meet Residents needs. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of three people staying in the Home were examined, for the purpose of case tracking. All of the basic information, concerning each person, was found to be in the files examined. That was, their name and date of birth, their preferred name, their next of kin, their GP, their Social Services Dept Care Manager and their date of entry into the Home. As a result the staff in the Home knew who to contact, should the need arise. Records of the Registered Provider/Manager’s initial assessment of each person were found in each file, together with completed Individual Plans of care for them, although none were dated. Records of the risk Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 12 assessment on each person were also available. All of these records were in the process of being updated. As a result staff would be appropriately informed of the needs and means of meeting those needs for each person staying in the Home. One of the files seen contained a full update and was well maintained with all necessary data, but the other two files were still awaiting these changes and so lacked the full information provided in the first file examined. However, the Registered Provider/Manager stated that an oversight of these changes was being provided by an ‘independent consultant’ and that as a result all files would be updated to this new improved level in the near future. The ‘independent consultant’ visited the Home during this visit, and was spoken with. It was also found that the Registered Provider/Manager had not provided the required information for those people suffering with dementia. As a result, all three of the files examined, did not have records of each person’s possible limitations of choice, freedom and decision making, despite it being found that each of the people suffered, to a greater or lesser extent, with dementia. The Registered Provider/Manager was found not to be recording in full the 6 monthly reviews of care of each person staying in the Home. This was recommended, by the Commission, to ensure that peoples needs are kept up to date. The Registered Provider/Manager said that she did undertake a review of each person, but this would only be recorded as a one line entry in the records. However, a full case review is recommended by the Commission, similar to that provided when Social Services Dept undertake a formal review of care. All of the files were easy to read and in the main satisfactory entries had been made by the care staff. The Registered Provider/Manager had reviewed the records of each person at regular intervals. However, as stated earlier, only one of the files were well organised, with different sections, and only this file contained a ‘confidential’ records section. Again, the funeral arrangements of only one person were contained in their files. Staff were observed talking and assisting people with meals and in the lounge of the Home. This was seen to be done very positively, with a relaxed atmosphere, which seemed to be enjoyed by the people staying in the Home. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to people staying in the Home were examined, and a good system was found to be in use. Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 13 Discussion was held with people about life in the Home. They said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They also said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being. One person said that ‘Staff are very good, always doing things my way.’ Another said ‘I have never had any problems with staff, none whatsoever.’ A relative visiting said that she could see her mother wherever she wished. She said that ‘so far’ her mother had been treated well (having not been in the home very long). All staff were observed to be very caring in their dealing with people staying, and spoke to them in a pleasant manner. Discussions were also held with Staff, and very positive ways were described of assisting people within the Home. Royal Manor DS0000002155.V362366.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): Standards 12, 13, 14 & 15. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Peoples preferred lifestyles were respected by the Home, although insufficient activities were provided to meet peoples interests and needs. All people staying in the Home were given a wholesome and appealing diet in pleasant surroundings. EVIDENCE: Two people staying in the Home were asked about the activities provided. They said that activities including game playing and occasional trips. Two staff were also asked about activities. One said that dominoes, skittles, card games and newspaper reading were regularly arranged or provided. The second confirmed that these activities took place, but said that they did not take place at regular intervals, and so thought that more should be done within the Home. The Home did not have an Activities Coordinator. People staying in the Home said that they decided when they got up and went to bed – ‘I please myself when I get up and go to bed.’ Another person said that ‘I have a bath three times a week,’ which was confirmed by this person’s daughter. Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 15 Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘Oh yes, I always see my daughter in private.’ Another said ‘Always in private, as you can see, my daughter is with me today.’ This was also confirmed by discussion held with staff, who said that relatives could be seen by people staying in the Home in the lounges or in their own bedrooms. Two people staying in the Home that were spoken with had a mixed response when asked how staff entered their bedrooms. One said that ‘Staff knock and wait for me to say ‘come in’ before doing so.’ But another said that ‘Staff always knock, but always just walk in.’ While talking with one person, in their bedroom, a staff member called to deliver a cup of tea. The staff member simply opened the door and walked in, with no knock whatsoever. This indicated that peoples privacy and dignity were not always respected by staff. People staying in the Home were able to say that the Home provided good meals and that a good choice was available at the breakfast, and teatime meals, which staff also confirmed. Staff said that at dinner time (lunch time) only one meal was served, although alternatives would be provided if it were known that someone staying in the Home actively disliked what was being provided. A notice board was seen in the Home giving details of the one and only main meal provided at dinner time. Staff also said that drinks and snacks were always provided between meals, and that mealtimes were never rushed, which was witnessed during this visit to the Home. Two staff were also asked, when people needed assistance to managed their meal, how many people they might help at the same time. Both staff said that people were seated at tables so that they could assist two people at the same time, if this were needed. Royal Manor DS0000002155.V362366.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): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Registered Provider/Manager would be addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: People staying in the Home spoken with said that if they were not satisfied with something they would probably tell their relatives first, but that the relatives would tell the Registered Provider/Manager. Since the last visit made to the Home, in April 2007, the Commission had received one anonymous complaint. This was investigated with the assistance of the local Social Services Dept, with a satisfactory conclusion. Aside from the above issue the Registered Provider/Manager said that no further complaint has been raised with her. During this visit to the Home the complaint procedures were seen for both written and verbal complaints. The Registered Provider/Manager’s complaints procedure detailed that all complaints would be responded to by her within at least 28 days. The Registered Provider/Manager had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. This meant that a procedure was in place to allow staff to inform the Registered Provider/Manager of any inappropriate actions by other staff. Two staff spoken with said that they either had received training or were shortly due to attend training on Safeguarding Adult and Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 17 Whistle Blowing. However the Registered Provider/Manager was not sure that she had information in the Home on the Public Interest Disclosure Act 1998 or the Dept of Health guidance called ‘No Secrets’. The Registered Provider/Manager confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Provider/Manager ensured that all staff understood physical and verbal aggression that may have been expressed by people staying in the Home. She also said that a policy was available to staff stating that they could not benefit from Residents wills, which was also understood by the staff, with whom discussions were held. Royal Manor DS0000002155.V362366.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): Standards 19, 20, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was suitably maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the public areas of the Home, and all bedrooms of the people staying in the Home were seen. The Home was pleasantly decorated throughout, and the lounges and dining room were pleasant to sit in, and were provided with appropriate items for those staying. The bedrooms provided sufficient space and provision for each Resident. Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 19 A call system was also available throughout the Home. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. The Registered Providers had provided appropriate furnishings in all locations seen during this visit, aside from the issues mentions below: The bedroom identified to the Registered Provider/Manager needed urgent attention to remove the very poor odour within it. In the bathroom numbered ‘8’ the staff pull cord was seen to be broken and to hang out of reach of somebody using the bath. In bedroom 11, in the ensuite toilet, the linoleum floor covering was found to be badly puckered up around the toilet. This proved easy to almost straighten out, but was therefore easy to again pucker up and create a danger to the person using the bedroom/bathroom. The floor covering needed to be tacked to the floor. None of the bedrooms were found to have locks fitted that could be used by people staying in the Home. The majority of bedrooms were also found to only have one comfortable armchair in them, rather than the two recommended by the National Minimum Standards. Much of the Home’s garden was untended and needed attention to make it pleasant for people to sit in. Chairs provided in the lounges were plastic covered. This would cause strong perspiration for those sitting on them, and should be changed for more comfortable, yet appropriate covering for the Home and its function. In both public toilets, near to the Registered Provider/Manager’s office, shaving foam, belonging to people staying in the Home was found, which needed to be returned to the appropriate bedrooms. Royal Manor DS0000002155.V362366.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): Standards 27, 28, 29 & 30. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. A good level of care staffing was provided to meet the needs of people staying in the Home. Inconsistent recruitment practices mean the Residents were not fully safeguarded. EVIDENCE: Levels of nursing and care staffing were examined for the 3 weeks beginning 31 March 2008. This showed that a good level of staffing was being provided. At the time of this visit to the Home it was found that over 80 of care staff had a qualification of at least NVQ level 2 in Care, and a further 2 staff where currently undertaking the course. The records of two new staff employed during the past 12 months were examined to see whether the Registered Provider/Manager had obtained all relevant information about them. It was found that almost all information had been obtained. However, for both members of staff only 1 written reference had been obtained, even though the Regulations states that 2 references are required. One of the members of staff had apparently got relevant qualifications to the task of caring for Residents in a home, yet no copies had been taken of those qualifications. Lastly, the history of employment of one of the staff had only been taken over the previous 10 years, and not back to when they had left school. This was needed to allow the Registered Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 21 Provider/Manager to check whether the potential member of staff had worked in care in the past, to allow an additional reference to be obtained. All other information was found to be satisfactory. The Registered Provider/Manager said that new staff would be provided with induction and foundation training, which was confirmed by staff. She also said that all care staff were provided with at least three paid days training a year. The records of some of this training was seen. All staff also had an individual training and development assessment and profile. Again, this was confirmed by staff. Royal Manor DS0000002155.V362366.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): Standards 31, 33, 35, 36 and 38. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were not sufficiently robust to ensure that residential care was maintained at a positive standard. EVIDENCE: The Registered Provider/Manager was in the process of obtaining her qualification of an NVQ level 4 in Management, and she anticipated finishing the course within the next 12 months. This qualification was needed to ensure that she was appropriately training to manage the Home. However, she already held a nuring qualification. The Registered Provider/Manager said the Quality Assurance information was currently being prepared, but was not available at the time of this visit to the Home. As a result no annual development plan was available and no internal Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 23 audit of the Home had taken place. Residents Surveys, she said had been prepared and one such survey had been carried out, but it had not been published. She also said that a questionnaire had been prepared to obtain the views of relatives of those staying in the Home, on how the Home was achieving goals for their Residents, but again, this was not in use at the time of this visit. This information was needed to ensure that the Registered Provider/Manager was meeting all the needs of those staying in the Home, as well as the needs of staff and the administrative needs of the Home. The Registered Provider/Manager stated that the she did not hold any savings money on behalf of those staying in the Home. Peoples purchases and hairdressing etc were paid by the Registered Provider/Manager, when necessary, and the people, or their relatives, were then billed for these amounts. Two staff members were asked about the supervision they received from the Registered Provider/Manager or other senior staff in the Home. This was needed to ensure that the Registered Provider/Manager was aware of the needs of her staff and of the people staying in the Home, and made plans to meet those needs. One said that this was done approximately on a 3 monthly basis, and the other member of staff said that this was done, again approximately, twice a year. The Registered Provider/Manager agreed with these two statements, saying that some staff received supervision almost once every two months, but that this did not apply to all of her staff. The training required by the Regulations was examined. The training records showed that Fire Safety training and Infection Control training had been provided for all appropriate staff in the Home. Moving and Handling training had been provide for all care staff expect for 3 member of staff. First Aid had been provided for all except for 2 member of staff, and again, only 3 members of staff were still in need of Food Hygiene training. Both members of staff spoken with during this visit, were able to say that they had received all of the above training within the appropriate timescales. In addition to the above statutory training, the Registered Provider/Manager said that further staff training opportunities were provided, and included such courses as NVQ level 3 in Care, Continence training, Dementia Awareness, COSHH training, Safeguarding Adults and POVA training, Nutrition training, and Medication training. From copies of the Home’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that all necessary maintenance and repairs were being appropriately addressed. The Registered Provider/Manager was able to show that the Home had complied with the majority of legislation applicable to its operation, although she said she did not have information on the Management of Health and Safety Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 24 at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations of 1992 or the Provision and Use of Work Equipment Regulations of 1992. The Registered Provider/Manager was not able to show that the she had provided risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff. She had also not provided a written statement of the policy, organisation and arrangements for maintaining those safe working practices. Finally, the Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 2 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 26 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 complete Residents Guide must be available for resident’s to ensure they have sufficient information about the home to maintain their rights. (This issue has been outstanding since April 2006) 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. (This issue is outstanding from the inspection report dated 18 April 2007) The Registered Provider/Manager must ensure that each person, 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 person’s records. This is to ensure that people understand their rights while staying in the Home. (This issue has been outstanding since April 2006) DS0000002155.V362366.R01.S.doc Version 5.2 Page 27 Timescale for action 16/06/08 2. OP7 15(2)(b) 16/06/08 17 Sch 3 No 3(q) Royal Manor 3. OP19 12, 13 & 23 The bedroom identified to the Registered Provider/Manager needed urgent attention to remove the very poor odour within it, to ensure that this room was pleasant to the person staying there. In the bathroom numbered ‘8’ the staff pull cord was seen to be broken and to hang out of reach of somebody using the bath, therefore they would be unable to summon staff when needed. In bedroom 11, in the ensuite toilet, the linoleum floor covering was found to be badly puckered up around the toilet. This proved easy to almost straighten out, but was therefore easy to again pucker up and create a danger to the person using the bedroom/bathroom. The floor covering needed to be tacked to the floor. 16/06/08 4. OP29 19(1)(5) and Schedule 2 The Registered Provider/Manager must ensure, when appointing new staff, that all the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004, are obtained. Of two staff’s records examined, it was found that only one reference had been obtained for both members of staff. One member of staff had apparently obtained appropriate qualification prior to moving to the Home, but copies of those qualifications had not been obtained. In addition, where a person has worked in a position of ‘care’ in the past, a references must be obtained from that DS0000002155.V362366.R01.S.doc 16/06/08 Royal Manor Version 5.2 Page 28 employer, to ensure the person had not been dismissed due to offences against those looked after. (This issue is outstanding from the inspection report dated 18 April 2007) 5. OP33 24 The Registered Provider/Manager must address the Quality Assurance issues listed within Standard 33.1 to 33.7. These are needed to ensure that the Registered Provider/Manager is meeting all the needs of those staying in the Home, as well as the needs of staff and the administrative needs of the Home. (This issue is outstanding from every inspection report dating from 2002) Supervision must be provided for all care staff. This is needed to ensure that the Registered Provider/Manager is aware of the needs of her staff and of the people staying in the Home, and makes plans to meet those needs. Mandatory training must be provide for the 3 staff requiring Moving and Handling training, for the two staff requiring First Aid training, and the 3 staff requiring Food Hygiene training. This is needed to ensure that all staff have the knowledge to meet the needs of people staying in the Home, and to ensure that the Home is run to satisfactory standards. 30/06/08 6. OP36 18(2)(a) 16/06/08 7. OP38 13(3) & 18(1)(c) 31/08/08 Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 No. 1. Good Practice Recommendations The Residents Guide should contains information from people staying in the Home about their opinions of the Home. Every entry in peoples files should be dated. The Registered Provider/Manager should complete formal 6 monthly reviews of care with people staying in the Home. Those attending the review should include the person themselves, where possible their relatives and representative, and staff from the home. Where Social Services Depts carry out annual reviews of care this could be one of the 6 monthly reviews. Each person’s file should be well organised with dividers to indicate different sections of the file. Each person’s file should contain a ‘confidential’ section. This section should be used for records made by staff that the person staying in the Home should not see and for information passed to the Home by professionals to which the person had not been made party. The funeral arrangements of people staying in the Home should be recorded in each file. 2 OP7 3. OP12 A larger number of activities should be provided for people staying in the Home, to ensure that people are appropriately entertained. Consideration should be given to providing an Activities Coordinator. Staff should be made aware of those Residents who should be encouraged, following staff knocking on their bedroom door, to invite staff into their bedrooms and those Residents who can no longer do this. 4. Royal Manor OP15 A choice of at least two main meals should always be DS0000002155.V362366.R01.S.doc Version 5.2 Page 30 provided at lunch times. Staff should only be required to assist one person at a time with their meal. If necessary other people awaiting their meal should be left in the lounge, or in their bedroom, until a member of staff was able to assist them with all of their meal at one time. Meals should be kept hot to allow this take place. 5. OP18 A copy of the Public Interest Disclosure Act 1998 and the Department of Health’s document ‘No Secrets’ should be obtained and be available in the Home at all times. This is to ensure that the Registered Provider/Manager is aware of the action to take when complaints are made about the actions of her staff. None of the bedrooms were found to have locks fitted that could be used by people staying in the Home. This is recommended within the National Minimum Standards. The majority of bedrooms were also found to only have one comfortable armchair in them, rather than the two recommended by the National Minimum Standards. Much of the Home’s garden was untended and needed attention to make it pleasant for people to sit in. This is recommended within the National Minimum Standards. Chairs provided in the lounges were plastic covered. This would cause strong perspiration for those sitting on them, and should be changed for more comfortable, yet appropriate covering for the Home and its function. In both public toilets, near to the Registered Provider/Manager’s office, shaving foam, belonging to people staying in the Home was found, which needed to be returned to the appropriate bedrooms. 7. OP31 The Manager should complete the course she is currently undertaking to acquire an NVQ level 4 in Management, by 31 March 2009. The Registered Provider/Manager should arrange for all care staff to receive supervision at least 6 times a year; once every 2 months. The Registered Provider/Manager should ensure the Home complies with the Management of Health and Safety at DS0000002155.V362366.R01.S.doc Version 5.2 Page 31 6. OP19 to OP26 8. OP36 9. Royal Manor OP38 Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. The Registered Provider/Manager should provide risk assessment on all working conditions of staff; that is for care staff, catering staff and domestic staff. The Registered Provider/Manager should also provide a written statement of the policy, organisation and arrangements for maintaining the above safe working practices. Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 32 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 Royal Manor DS0000002155.V362366.R01.S.doc Version 5.2 Page 33 - 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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