Inspection on 25/04/06 for Royal Manor

This inspection was carried out on 25th April 2006.

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 17/04/07

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 Mr Steve Smith Unannounced Inspection 25th April 2006 09:30 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.V288447.R01.S.doc Version 5.1 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.V288447.R01.S.doc Version 5.1 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.V288447.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 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 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, well maintained garden area to the front and side of the property. The garden area is easily accessed by Residents from the building. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 7 hours. Discussion was held with the Manager and one of the Residents. Some of the Home’s records were seen, and the public areas of the Home and all bedrooms were examined. The fees for staying within the Home range from £315.00 to £426.00 a week, depending on the room occupied and whether residential or nursing services are required by the Resident. What the service does well: What has improved since the last inspection? Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 6 A complete statement of purpose was provided within the Home and the fees payable were clearly indicated. Since the last inspection in January 2005 the Registered Provider/Manager has ensured that there is evidence to show that Residents and relatives are involved in drawing up and evaluating the plan of care for each Resident. The Home was reasonably decorated throughout. Staff are now appropriately trained to guard against Residents being harmed. What they could do better: A Residents Guide needs to be provided in all bedrooms of the Home. Residents’ files need to be updated to ensure that they contain all relevant information laid out in the Regulations and in the National Minimum Standards. Residents’ files must also contain information about the Resident’s plans for their funeral, and staff to be trained in dying and bereavement issues. Residents’ care plans need to be made available to all Residents with the ability to understand them. The Registered Provider/Manager needed to also provide additional activities in the Home to ensure that Residents were appropriately entertained. The Registered Provider/Manager needs to extend the complaints recording system to ensure that verbal complaints were appropriately recorded and acted upon. A number of repairs and improvements were needed around the Home. The Registered Provider/Manager needed to review the working arrangements of all care staff to ensure that staff did not work excessive amounts of time each day. When new staff were appointed the Registered Provider/Manager needed to ensure that all details required by Regulation 19 and Schedule 2 were met. The Registered Provider/Manager also needed to extend the work begun to meet the Quality Assurance standards of the Home. Regular supervision of all care staff needed to be provided, at least at 2 monthly intervals of time. Moving and Handling training was needed in the Home for all nursing and care staff on an annual basis. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 7 The Registered Provider/Manager needed to also provide risk assessments on all working practice issues undertaken by catering and domestic staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 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.V288447.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 3. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. The Registered Provider/Manager’s statement of purpose and Residents Guide were appropriately completed, although the Residents Guide had not been distributed to all Residents staying in the Home. All new Residents moving to the Home were appropriately assessed prior to their admission. EVIDENCE: The Registered Provider/Manager had provided a statement of purpose for the Home together with a Residents Guide. Both these documents had been appropriately completed, and included details of how to contact the Commission, the local Social Services Dept and the local Health Authority. However, copies of the Residents Guide had not been distributed to the Residents staying in the Home. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 10 All Residents had been provided with copies of the statement of terms and conditions of residency in the Home or a contract if purchasing their care privately. When new Residents were admitted to the Home, the Manager was provided with a summary of needs of each person, completed by the Care Manager supporting each Resident. If the Resident was self-funding from the outset, the Manager said she would complete her own summary of needs. Standard 6 does not apply to this Home. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. Residents’ health and personal care needs were being fully met, as demonstrated within care plans. Medication was appropriately distributed to meet Residents needs, although some minor improvements were required. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. They also contained the initial assessment completed by the Social Services Care Manager that placed each Resident at the Home, and the Manager had completed her own initial assessment of needs for the four Residents. There were also copies of the ongoing care plan and risk assessment available in each file examined. However, the Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 12 name of the designated keyworker for each Resident was missing from three of the files examined. None of the files contained a copy of a letter given to the Resident, before admission, to say that the Home was suitable to meet the Resident’s needs in respect of their health and welfare. The Registered Provider/Manager had not provided details of each Resident’s possible limitations of choice, freedom or decision making abilities in any of the records or reviews of care undertaken in the Home. The files showed that good records of events affecting each Resident were kept by the Home. The Residents files had not been shown to each Resident, or their representative, on either a monthly basis or six monthly basis, when formal reviews of care should have been undertaken. The Registered Provider/Manager said that a confidential section, in each file, was not a practice provided by the Home. However, the files were easy to read, with regular entries from staff of the Home, although all of the files examined were poorly organised. Staff of the Home were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents were examined, and a good record was found. However, one issue needed attention: In a number of places throughout the Medication Administration Record (MAR) sheets a ‘O’ was used. The definition on the MAR sheet for a ‘O’ was ‘Other’ but staff of the Home had failed to define what ‘O’ meant. Two Residents were spoken to about life in the Home. They both 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 said that their care needs were always met with dignity and respect. As a result, they said they felt very safe in the Home, and appeared to have a strong sense and appearance of well being. One of the Residents was asked what funeral plans they had made for themselves and whether these had been discussed with staff. The Resident said that all plans had been made with their family, but these had not been discussed with the Registered Provider/Manager. At the time of the last inspection in January 2006 the Registered Provider/Manager was encouraged to provide training for staff on dying and bereavement, but this had not been provided at the time of this inspection. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. Residents’ preferred lifestyles were respected by the Home. They were able to receive visitors and to exercise choice and control over their lives. Residents were also given a wholesome and appealing diet. EVIDENCE: Two Residents were asked about the activities provided in the Home. One spoke of her attendance away from the Home at a day centre and the work she had been doing there to extend her computer skills. They both said that singers regularly attend the Home, and that representatives from local churches visit at least weekly. However, activities within the Home seemed to be very limited. This issue was highlighted during the inspection of January 2005, but so far the Registered Provider/Manager had not been able to address this. Both Residents said that they felt very safe living in the Home. Staff respected their confidences and all their needs were met with dignity, respect and choice. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 14 One of the Residents said that they could go to bed and get up at times of their own choosing. This Resident also said that they would like to go to bed at 10.30 pm, but is most often left till 11.30 pm for help transferring into their bed; ‘when I am put to bed I am always the last, and I get fed up of it.’ This was later discussed with the Registered Provider/Manager who felt that this would not happen. However, this needed to be resolved with the staff providing the care at that time of night. One Resident said that they could choose or change their bath times and that currently they chose to bath twice a week. One of the Residents spoken to said that there was a choice provided at all meal times: ‘If you don’t like it they will give you something else’. The inspection of the kitchen found it to be well maintained. One Resident spoken to said that they were not aware of whom their keyworker was. One of the Residents said that Residents could go shopping in the local town if they wished to do so, although relatives would need to take them. In addition, copies of postal voting forms were observed in Residents files during the inspection. Relatives and friends of Residents were able to visit at any time, and could always be seen in private, which was confirmed by relatives seen during the inspection. One of the Residents spoken to said that their mail was always delivered unopened, and that this was a ‘non-smoking’ home. However, Residents said that they had not seen their files. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome group is ‘Adequate’. This judgement has been made using available evidence including a visit to the Home. Written complaints made to the Registered Providers were appropriately addressed to meet Residents needs, although further improvements were needed. The protection policies and procedures provided by the Home meant that Residents were well protected EVIDENCE: One of the Residents spoken to said that they would raise a complaint with the Registered Provider/Manager if something troubled them. The Commission had not received any notice of complaint since the last inspection of this Home. Good procedures and satisfactory records were maintained for written complaints. They showed that the Registered Provider/Manager maintained a good system for Residents complaints and that written complaints and replies were recorded. The Home’s complaints procedure detailed that all complaints would be responded to by the Registered Providers within at least 28 days. However, the Home was not recording verbal concerns or complaints, and as most complaints would be made verbally this was judged to be a serious omission. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 16 The Registered Provider/Manager had an Adult Protection procedure that included a ‘Whistle Blowing’ policy. She also had copies of the Public Interest Disclosure Act of 1998 and the Dept of Health’s policy called ‘No Secrets’. She was able to confirm that she would follow up all allegations and incidents of abuse promptly 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 by Residents. She also said that there was a policy available to staff stating that they could not benefit from Residents wills. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: All bedrooms and public area in the Home were examined during this unannounced inspection. The bedrooms were well presented, with many individual touches provided by the Residents, their relatives or by the Home. All of the bedrooms were found to be large and spacious for each Resident. The Home was provided with two sluices. The kitchen was examined, which was well maintained, with a good variety of food for all meals for Residents. The laundry was also visited, where all clothing was marked with Residents names. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 18 However, a number of items needed attention, which are detailed below: The seating provided in all lounges included plastic covered upholstered chairs. These were found to be comfortable seats but the plastic covering caused the person seated to perspire, as was found during the inspection. Covering the seats with cloth covers would improve matters, until such time as it was deemed necessary to purchase more appropriate seating. In the lounge next to the office the carpet was damaged in an area across the lounge floor, causing a trip hazard to Residents. Emergency staff call lines in toilets could not be reached by someone who might have fallen, as they ended at approximately waist level. In bathroom 8 the emergency staff call line could not be reached by a Resident seated in the bath. Most single bedrooms were provided with only one double electric socket and only two or three double electric sockets in double bedrooms. Many bedrooms were found not to have sufficient armchairs and no table. The flooring on the first floor by the lift and into bedroom 9 creaked very loudly indeed when walked upon and needed attention. In the toilet in bedroom 11, carpeting had been removed from the area around the toilet. One bedroom identified during inspection was found to have a poor odour that needed attention. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. The quality in this outcome group is ‘Good’. This judgement has been made using available evidence including a visit to the Home. More than sufficient care staffing was provided within the Home to meet Residents needs. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the two weeks beginning 3rd and 10 April 2006, the Home was providing between 8 and 20 hours of care a week more than the minimum amount required for 25 Residents at the High Dependency level. These figures were calculated without the Registered Provider/Manager’s working time included, as recommended by the Residential Forum. Across the two weeks reviewed, 5 staff were found to have worked at least two double shifts, amounting to 13 hours in one day. This does not encourage staff to meet the needs of Residents in a kindly, understanding and patient manner, and is to be strongly discouraged. At the time of this inspection it was found that more than 50 of care staff had a qualification of at least NVQ 2. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 20 The records of three staff employed since April 2002 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 for all three staff. The Registered Provider/Manager had obtained all necessary information for two of the staff. However, one member of staff had only provided one reference, a full employment history had not been provided, and nor had this member of staff provided a statement to say that they were physically and mentally fit to carry out work in the Home. Staff induction and foundation training was provided for all new staff and the Registered Provider/Manager said that all staff were provided with at least three paid days training a year. All staff also had an individual training and development assessment and profile. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38. The quality in this outcome group is ‘Adequate’. This judgement has been made using available evidence including a visit to the Home. The Registered Provider/Manager needs to fully address the Quality Assurance issues to ensure Residents’ care was maintained at a positive standard. EVIDENCE: The Registered Provider/Manager was required, by the Care Home Regulations, to become qualified to NVQ level 4 by the end of December 2005. However, she has not undertaken this course of study and said, during the inspection, that she intended to retire in 18 months time, i.e. by September 2007. As a result, therefore, she did not intend to take the qualification. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 22 The Registered Provider/Manager had started to meet the quality assurance standards set for the Home. She had begun to develop an annual development plan for the Home, but this work had not been completed at the time of this inspection, as it only included maintenance issues. Residents’ surveys had apparently been developed but had not been used. Similarly, the Registered Provider/Manager said that questionnaires had been developed for relatives and visiting professionals, but again these had not been put into practice. However, the Registered Provider/Manager was of the opinion that her staff would be able to say how they ensured that Residents continued to learn and develop while coping with their deteriorating health needs. This Standard was not met at the time of the last inspection in January 2006. As a result the Registered Provider/Manager was provided with an Immediate Requirement notice, as this issue had been outstanding since 2002. As already stated, some work has been undertaken to try to address this shortfall but more was needed. The Registered Provider/Manager explained that the Home does not hold any money on behalf of Residents. When money needed to be spent on a Resident’s behalf, the Home bore the cost and billed the relatives after each occasion this had occurred. The supervision needs of staff were discussed with the Registered Provider/Manager. She clearly stated that all staff were observed while carrying out their duties, but staff were still not being individually supervised on a one to one basis. The training provided for staff was examined. This showed that Fire training, First Aid training, Food Hygiene and Infection Control training had been provided to all relevant staff and was up to date. However, Moving and Handling training was found to be two years out of date. In addition to the above required training, the Registered Provider/Manager said staffing were also provided with training on Healthy Eating and Nutrition, Medication Training, Dementia training, Wound Management, Prevention of Bed Sores, Customer Hospitality and Basic Computer Skills. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Registered Provider/Manager said that the Home had complied with the majority of legislation applicable to its operation, although she said she did not have information on the Workplace (Health, Safety and Welfare) Regulations of 1992 or the Provision and Use of Work Equipment Regulations of 1992. Risk assessments had been carried out for all safe working practices in the Home that related to the care staff’s tasks. However, this had not been done for catering and domestic staff tasks. The Registered Provider/Manager said Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 23 that she had not provided a written statement of the policy, organisation and arrangements for maintaining those safe working practices. However, the Manager ensured that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She also had ensured, with the assistance of the Fire Service, that fire safety notices were posted in relevant places around the Home. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 3 3 2 3 3 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.V288447.R01.S.doc Version 5.1 Page 25 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 Residents Guide must be provided to ever Resident staying in the Home. Each Resident’s file must contain a copy of a letter sent to the Resident, prior to admission, to say that the services provided in the Home are suitable to meet the Resident’s needs in respect of their health and welfare. The Registered Provider/Manager must ensure that each Resident, or their representative, has had the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome must be recorded in each Resident’s records. When staff enter a ‘O’ in the Medication Administration Record sheets they must ensure that it is defined. Residents care plans must be made available to them. (This issue is outstanding from the inspection report dated 1 December 2005) The Registered Provider/Manager DS0000002155.V288447.R01.S.doc Timescale for action 20/06/06 2 OP7 14 20/06/06 3 OP7 17 & Sch. 3 20/06/06 4 OP9 13 20/06/06 5 6 Royal Manor OP14 OP16 15 22 20/06/06 20/06/06 Page 26 Version 5.1 7 OP19 16 8 OP19 16 & 23 9 OP24 16 10 OP24 16 11 OP29 19 12 OP33 24 must maintain a system for recording and responding to verbal complaints. The damaged carpet in the lounge next to the office must be repaired or replaced, to prevent it being a trip hazard to Residents. Emergency staff call lines in toilets and bathrooms must be extended to just above ground level. In bathroom 8 the emergency staff call line must be lengthened to ensure it can be reach by a Resident sitting in the bath. All single bedrooms must be provided with at least two double electric sockets and all double bedrooms with at least 4 double electric sockets. All single bedrooms must be provided with comfortable seating for two people or four people in double bedrooms. They must also be provided with a table to sit at for each Resident occupying the bedroom. However, this could be discussed with each Resident, or their Representative, and not provided if they agreed with this, and if this was recorded within each Resident’s Care Plan. The Registered Provider/Manager must check, and hold documentary evidence, that all staff employed in the Home, since April 2002, have satisfied the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, as amended during 2004. The Registered Provider and Manager must address the issues listed within Standard 33.1 to 33.6. (This issue is outstanding from the DS0000002155.V288447.R01.S.doc 20/06/06 31/07/06 31/10/06 31/07/06 20/06/06 31/07/06 Royal Manor Version 5.1 Page 27 13 OP36 18 14 OP38 13 15 OP38 18 16 OP38 13 & 18 inspection report 2002) The Registered Provider/Manager must carry out formal supervision for all care staff. All of the nursing and care staffing must receive training in Moving and Handling on an annual basis. The Registered Provider/Manager must ensure the services provided by the Home comply with the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. The Registered Provider/Manager must provide risk assessments on all working practice issues undertaken by catering staff and domestic staff. 20/06/06 30/09/06 20/06/06 31/07/06 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 OP7 OP7 No. 1 2 Good Practice Recommendations Each Resident’s file should contain the name of their keyworker and able Residents to be informed of their keyworkers name. Residents files should be well organised with dividers separating each section of the file. This would make the finding of information in the files much simpler. Formal reviews of care should be undertaken at 6 monthly intervals. Those taking part should at least include staff from the Home, the Resident and their relatives, particularly the ‘personal representative’. The review of care should be shown to the Resident (or representative) for signature. The keyworker’s monthly update of Resident’s records should be shown to the Resident, where this is deemed possible. A record should be made on each occasion of DS0000002155.V288447.R01.S.doc Version 5.1 Page 28 3 OP7 4 OP7 Royal Manor 5 6 7 8 OP7 OP11 OP11 OP12 9 10 11 12 13 14 15 OP12 OP12 OP14 OP19 OP19 OP19 OP19 16 OP27 17 18 OP36 OP38 any comments made by the Resident and the Resident should be asked to sign the record. The file also should record when the Resident is unable to review their file due to their limitations. All Residents files should contain a confidential section, as necessary. The Registered Provider/Manager must ensure that all Residents are asked about their funeral plans within a short time of their admission to the Home. Staff should receive training on dying and bereavement. (This issue is outstanding from the inspection report dated 9 January 2006) Additional activities should be arranged to ensure stimulation for all residents. (This issue is outstanding from the inspection report dated 9 January 2006) The Manager should discuss with night staff the system used when assisting Residents into their beds, to ensure that the order in which Residents are assisted is different each night. The Registered Provider/Manager should ensure that Residents are informed of whom their keyworker is. There should be a system in place to ensure that able residents have access to all of their records. All seating in the lounges should be covered with appropriate cloths to prevent Residents perspiring excessively when seated. The flooring on the first floor by the lift and into bedroom 9 should be repaired to prevent the loud creaking sound when walked upon. In the toilet in bedroom 11 carpeting should be provided around the toilet. The odour should be removed from the bedroom identified during the inspection. The Registered Provider/Manager should review the length of time nursing and care staff are allowed to work in the Home, and where possible limit this to no more than one shift per day, of approximately 8 hours, and 40 hours each week. Staff should receive formal supervision two monthly that covers care practice, philosophy of the home and career development. The Registered Provider/Manager should provide a written statement of the policy, organisation and arrangements for maintaining safe working practices in the Home. Royal Manor DS0000002155.V288447.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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