Inspection on 09/01/06 for Royal Manor

This inspection was carried out on 9th January 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 25/04/06

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 Janet Morrow Unannounced Inspection 9th January 2006 06:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Royal Manor DS0000002155.V276663.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.V276663.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.V276663.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 Brief Description of the Service: Royal Manor is a 25 bedded care home that provides both nursing and personal care. Royal Manor 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 rooms are located over 2 floors. All floors are 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 lounge and dining areas. 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 accessible by residents from the building. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over 6.5 hours. Care records and staff records were examined. A partial tour of the building was made. Five members of staff, six of twenty-four residents and four relatives were spoken with. A relative were contacted by telephone following the inspection. An anonymous complaint received at the office of the Commission for Social Care Inspection was investigated as part of this inspection. What the service does well: What has improved since the last inspection? What they could do better: The management of the home needs to take prompt action on outstanding requirements to ensure it meets its legal obligations, particularly in relation to staff supervision, consultation with residents about their care, quality assurance and staff recruitment procedures. • Evidence of Criminal Record Bureau checks must be available for all staff. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 6 • • • A system for supervising staff should be in place. This would enhance the care provided and ensure that staff follow the home’s policies and procedures. This has been raised as an issue at previous inspections since February 2004. It should be clear that the home has discussed each individual’s care needs with them or with their representative and that the way they will be cared for has been agreed. This has been raised as an issue at every inspection since November 2002. Quality assurance systems are required to ensure that the quality of the care in the home is maintained and the opinions and views of residents and visitors are acted upon. Locks on doors and additional items of furniture should be provided to ensure greater privacy. Reasons not to do so should be recorded. Minor repairs should be attended to so that the quality of the surroundings are maintained. The statement of purpose and residents’ guide should contain all the information required by the Care Homes Regulations 2001. Additional staff training in adult protection procedures and care of the dying would enhance the care offered to residents. A greater range of activities to suit individual needs would provide better stimulation for all residents. 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.V276663.R01.S.doc Version 5.1 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.V276663.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 There was useful information available to enable prospective residents to make an informed choice but it did not fully meet legal requirements. There was sufficient admission information available to establish that the home could meet individual needs. EVIDENCE: The statement of purpose was examined and provided useful information for residents. However, there were several items of information missing that were required by Schedule 1 of the Care Homes Regulations 2001.These included insufficient detail on staff qualifications, the age range and sex of people cared for and whether nursing was provided. There was also no information on the arrangements for consultation with residents about the operation of the care home. Social activities were included as therapeutic activities but there was no information on whether any specific therapies, such as physiotherapy, were accessed by the home. There was no residents guide to the home available at the time of the inspection although the manager stated that one had been developed and previous inspection reports referred to it. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 9 A sample terms and conditions of residence was examined. This was not specific about who was responsible for fees and there was no breakdown of the costs of nursing, accommodation and personal care. Three residents’ care files were examined. All had an assessment in place that had sufficient detail to ensure individual needs could be met. There was information available from the assessment and care management process, where applicable. The home’s own assessment document would benefit from having additional information on oral health and foot care needs. This was recommended at the previous inspection in August 2005. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 11 Health care needs were generally met but consultation with residents and their representatives was inconsistent, which did not ensure that the care was agreed and appropriate. EVIDENCE: The three care files examined all had personalised care plans in place and there was written evidence to indicate that care was reviewed regularly. However, there was no evidence that consultation about care took place and those residents spoken with were not aware of their care plan. Consultation with residents about their care has been raised as an issue at every inspection since 2002 and an immediate requirement notice was therefore issued to rectify this. Weight and blood pressure were recorded regularly. Nutritional assessments, risk of pressure sores, risk of falls and continence assessments were recorded on the files examined, with appropriate action detailed where a risk was identified. Records of visits by health professionals were available, for example, optician and chiropodist. Residents and relatives interviewed confirmed these visits occurred. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 11 A complaint investigated as part of the inspection had stated that care needs at night were not met. However, examination of care records, direct observation and discussion with staff did not uphold the complaint. There were sufficient stocks of incontinence equipment and night care needs had been reviewed regularly in a specific individual’s case. Residents had access to drinks and snacks at night and had a choice about the time they wished to get up. This preference was also recorded on the files examined. The policy on death and dying was examined. This had comprehensive information on how to care for the dying as well as what to do in the event of a death. However, residents wishes regarding death were not recorded in the three care records examined. Staff had not undertaken training in care of the dying or in bereavement, although those interviewed where confident in their ability to provide appropriate care. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14 Residents were assisted to have control over their lives, although additional activity would further enhance residents’ quality of life. EVIDENCE: Observation during the inspection showed that there was little activity or stimulation for residents, particularly those who required assistance. Most residents were sitting watching television. Outside entertainers were used and those residents and relatives spoken with had enjoyed the entertainment at Christmas. Those residents who were able pursued their own interests such as reading and had their own daily routines. The manager was aware of how to contact advocacy services and how many residents received assistance with their finances through power of attorney processes. However, there was no evidence to suggest that residents had access to their personal records. Individual rooms were personalised. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 13 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): 16 and 18 There were systems in place, which ensured that complaints were handled objectively and residents were protected, although additional attention to training would enhance this. EVIDENCE: The home had a complaints procedure that stated that complaints would be dealt with in twenty-eight days. Those relatives spoken to were aware of the procedure. There was a document available for recording complaints and the action taken to resolve them. The manager stated that there had been no internal complaints received since the last inspection. An anonymous complaint received at the office of the Commission for Social Care Inspection was investigated as part of this inspection and was not upheld. The home had an adult protection policy and copies of Derby and Derbyshire Local Authority Social Services adult protection procedures. Staff interviewed had undertaken training as part of National Vocational Qualifications (NVQ) training but had not undertaken the Local Authority training. The manager stated that there had been no incidents or allegations of abuse since the last inspection. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 14 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): 19, 24 and 25 The home was well maintained and provided safe and homely accommodation for residents but some improvements would further enhance their comfort. EVIDENCE: Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 15 The home was generally well maintained and was clean, tidy and odour free. However, the wooden panelling on one bath was damaged, the wallpaper in the same bathroom was peeling and the paintwork was marked. This was raised as an issue at the previous inspection in August 2005. Residents’ bedrooms were personalised and comfortable. However, not all bedrooms had two comfortable chairs, a table to sit at, a bedside light, a lock on the door or two double electrical sockets. There was no evidence on the three files examined that reasons not to provide these items had been discussed with residents and their families. This was raised as an issue at the previous inspection in August 2005. A random sample of water temperatures at different outlets was tested and found to be at a safe temperature. The manager stated that water temperatures were tested regularly. Radiators were guarded. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 16 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): 29 Recruitment procedures were generally clear but additional information was needed to fully ensure residents’ protection. EVIDENCE: Two staff files were examined. These had most of the recruitment information required by Schedule 2 of the Care Homes Regulations 2001, such as two written references, identity information and proof of qualifications. However, neither file had a Criminal Record Bureau check. The manager stated that these had been obtained but was not able to locate them during the inspection. An immediate requirement notice was therefore issued to rectify this. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 17 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): 33, 34, 35, 36, 37 and 38 The home was well managed, which ensured the health and safety of all involved but further improvements to records and quality assurance systems would ensure that residents’ rights were upheld, that the home was run in their best interests and that legal requirements were met. EVIDENCE: Although care staff interviewed stated that they were observed in their practice and had the opportunity to discuss care issues with trained staff, there was no formal staff supervision taking place. It was unclear, therefore, whether or not career development needs and the care philosophy of the home were discussed as part of supervision. There were no written supervision records. This was raised as an issue at previous inspections since February 2004. An immediate requirement notice was therefore issued to rectify this. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 18 The home had not developed any plan to assure the quality of the home. There was no formal quality assurance system or method of collecting views and opinions of the home. The views of relatives and visiting professionals had not been sought. This was raised as an issue at the previous inspection in August 2005 and was outstanding from 2002. An immediate requirement notice was therefore issued to rectify this. The manager stated that no one in the home acted as appointee for a resident and that the home did not administer any residents’ finances. Any cash or receipts for items such as hairdressing and chiropody were held by residents or their families and not stored by the home. Records were clear and legible but not all met the requirements of Schedules 1 – 4 of the Care Homes Regulations 2001. For example, there was information missing from staff records and the statement of purpose, as identified earlier in the report. A valid insurance certificate was on display and the manager stated that a business plan was available, although this was not examined during the inspection. Health and safety issues were addressed. Staff interviewed confirmed that training in fire safety, first aid and food hygiene were undertaken. Training certificates seen also confirmed this. A random sample of maintenance records showed that gas safety certificates, fire equipment and hoist maintenance were up to date. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 19 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 3 X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 3 3 1 2 3 Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15 (2) (b) & (c) Requirement The Registered Person must ensure that there is evidence to support that residents and/or their representatives are involved in drawing up, agreeing and evaluating plans of care. Previous timescales from November 2002 not met. Now immediate. A policy and procedure for supervision of staff must be developed and implemented. Previous timescale of February 2004 not met. Now immediate. Residents care plans must be made available to them. Previous timescale of 1.12.05 not met. All parts of the home must be kept reasonably decorated. Previous timescale of 1.12.05 not met. The information specified in Schedule 2 of the Care Homes Regulations 2001 must be available. Previous timescale of 1.12.05 not met. Now immediate. A system must be established for DS0000002155.V276663.R01.S.doc Timescale for action 23/01/06 2 OP36 18 (2) 23/01/06 3 OP14 15 (2) (a) 01/04/06 4 OP19 23 (d) 01/04/06 5 OP29 19 (1) (b) & Schd 2 23/01/06 6 OP33 24 (1) 23/01/06 Page 21 Royal Manor Version 5.1 7 OP1 4 (1) (c), Schd 1 5A (2) 8 OP2 9 OP2 5 (1) (b) 10 OP18 18 (1) (c) & 13 (6) 17 (2) & Schd 1-4 11 OP37 improving the quality of care at the home. Previous timescale of 1.12.05 not met. Now immediate. The statement of purpose must consist of the matters listed in Schedule 1 of the Care Homes Regulations 2001. The registered person must provide a statement sepcifiying the fees payable for accommodation, nursing and personal care. The terms and conditions of residence must include the amount and method of payment of fees. There must be arrangements in place to prevent residents being harmed, which includes staff training. Records must be maintained which include the information specified in Schedules 1, 2 and 4 of the Care Homes Regulations 2001. 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP1 OP3 OP11 OP12 OP14 Good Practice Recommendations The Statement of Purpose and Residents’ Guide should be reviewed to ensure that the information contained in them remains accurate. Assessment documentation should make reference to oral health and foot care needs. Staff should receive training on dying and bereavment. Additional activities should be arranged to ensure stimulation for all residents. There should be a system in place to ensure that DS0000002155.V276663.R01.S.doc Version 5.1 Page 22 Royal Manor 6 7 8 9 10 11 OP18 OP19 OP24 OP29 OP33 OP36 residents have access to their records. Staff should receive training in Derby and Derbyshire Local Authority Social Services adult protection porcedures. The wallpaper and bath should be refurbished in the identified bathroom. The items of furniture detailed in this standard should be supplied. Reasons not to do so should be recorded. A Criminal Record Bureau check should be in place in all staff records. Quality assurance systems should take account of residents, relatives and visiting professinals views of the home. Staff should receive formal supervision two monthly that covers care practice, philosophy of the home and career development. Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Royal Manor DS0000002155.V276663.R01.S.doc Version 5.1 Page 24 - 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. 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