Inspection on 13/06/05 for Spetisbury Manor

This inspection was carried out on 13th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Spetisbury Manor 06/09/07

Spetisbury Manor 15/12/06

Spetisbury Manor 22/05/06

Spetisbury Manor 17/03/06

Spetisbury Manor 26/11/04

Spetisbury Manor 13/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Spetisbury Manor Spetisbury Blandford Dorset DT11 9EB Lead Inspector Gloria Ashwell Unannounced 13 June & 11 July 2005 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 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. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Spetisbury Manor Address Spetisbury Blandford Dorset DT11 9EB 01258 857378 01258 858384 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Country House Care Limited Post vacant Care home only 25 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of four bedrooms from those listed may be used for shared occupancy at any one time: 1, 11, 15, 16, 19, 20 or 21 The Condition was met. Date of last inspection 26th November 2004 Brief Description of the Service: Spetisbury Manor was until recently known as Blair Manor. It is registered to provide personal care for a maximum of 25 older people in 21 rooms, 4 of which may be used as shared rooms by residents who have made a positive choice to share with each other. Mr Kevin Ellis is the Responsible Individual; he also owns another registered care home, Glenhurst Manor in Bournemouth. Spetisbury Manor has been without a registered manager since September 2004. The home is situated on the outskirts of the small village of Spetisbury. Some residents frequently travel in the homes’ courtesy car to go shopping in Blandford, Wimborne and Poole. Spetisbury Manor stands in four acres of grounds laid to attractive gardens leading down to the river Stour. The accommodation is on three floors with a passenger lift serving the first and second floors. Eighteen bedrooms have en-suite hygiene facilities, and there are assisted bathrooms and toilets on each floor. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was one of the two statutory inspections required in accordance with the Care Standards Act 2000. Since the last inspection no formal complaints against the home have been received or investigated. The inspection took place over two days; the inspector arrived (unannounced) at 13.35 on 13 June 2005. During the inspection she spoke to 11 residents and 3 care workers. The inspector observed staff interaction with service users, the carrying out of routine tasks and toured the premises, departing at 16.30. The inspector left a selection of ‘Comment Cards’ and prepaid envelopes (for return to the Commission) in the entrance hallway of the home. Additional information used to inform the inspection process included 5 subsequently completed Comment Cards. As agreed with a senior carer, the inspector returned to the home at 14.00 on 11 July 2005 and together with two senior carers considered other evidence relating to the National Minimum Standards, as described in this report. The duration of the inspection (both days combined) was 6 hours and 30 minutes. At conclusion of the first visit the inspector issued an Immediate Requirement regarding unrestricted upper floor windows presenting risks of accidental falling. The requirement was met by the date of the second visit. At conclusion of the second visit the inspector issued Immediate Requirements in respect of care and medicine records, recruitment practise and notification to CSCI of events which might place residents at risk of harm. What the service does well: Residents are assisted to maintain as much independence as possible and are encouraged to maintain contact with the local community. The premises are comfortable, with a spacious lounge and a large dining room, overlooking attractive gardens. Staff are kind and helpful to residents. Residents are treated with respect and their privacy is protected. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: This report contains 14 requirements and 10 recommendations, including some directly related to the quality of care, daily life and safety of the residents and others to the provision of adequate documentation to support and provide evidence of the care and administrative functions of the home. Service users do not have sufficient information to ensure their choice of this home will fully suit their needs. The home does not have an adequate service user guide and Statement of Purpose and must improve aspects of the pre-admission procedure to ensure prospective residents have sufficient information on which to base any decision to move in to the home. Health and personal care needs of residents are not being met due to inadequate records being available to guide staff in their work. Poor standards of practice with regard to risk assessment and care planning were identified and require significant improvement for resident’s health and welfare to be safeguarded. There should be recorded assessment of the premises by an Occupational Therapist, to ensure suitability and safety for the residents, staff and visitors. Recruitment systems must be improved to ensure no new staff commence work in the home until adequate evidence of suitability has been received. The home should be in the charge of a registered manager, who should oversee and direct care, improve staffing levels and arrangements for staff supervision and training. The Responsible Person must properly discharge his responsibilities, including notification to the Commission of recent events likely to endanger the safety and welfare of residents, and provision to the Commission of regular reports about the home. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 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. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 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 standard(s) 1, 3 & 6 Standard 6 is not applicable because the home does not provide intermediate care. The home does not have an adequate service user guide and Statement of Purpose despite related requirements having been made in previous reports. In consequence, prospective residents are not provided with sufficient information about the home, to assist them in their decision about where to live. A written contract is provided to each resident at the time they enter the home to ensure clarity regarding fees and what they do and do not cover. Prior to admission, the needs of each proposed resident are assessed to ensure the home will be properly able to meet them but the home does not then write to prospective residents confirming the ability to properly care for them. Prospective residents (or their representatives) are encouraged to visit Spetisbury Manor in advance of admission to establish their impressions of life at the home and the available accommodation. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 10 EVIDENCE: The ‘service user guide’ does not contain sufficient information about the home; for example it omits experience and qualifications of staff and residents views of the home. The records of a recently admitted resident included those of a pre-admission assessment carried out by a care worker when she visited the person at home. The inspector spoke with the resident who confirmed this and said that in advance of admission Spetisbury Manor was visited on a number of occasions and the available rooms viewed. Following pre-admission assessment, if the home decides to offer a place to a new resident, they do not write to the person stating that Spetisbury Manor will be able to meet their assessed needs; a related requirement has been made to address this shortfall in practice. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 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 standard(s) 7, 8 & 9 Staff do not have information necessary to provide correct care to each resident. Not all residents have a plan of care. For some residents, care needs are briefly and sometimes inadequately described in a written plan of care. Many care plans are seriously out of date and inaccurate. High risk behavioural and health aspects e.g. aggression, diabetes, asthma, are frequently overlooked in care plans. There is not a reliable system for identifying and minimising risks to residents prone to falling or other harm. Arrangements for protecting residents from risks of medicine errors must be improved; only one member of staff has received training in medicine handling and some improvements to the record keeping associated with medicine handling are necessary to ensure that residents continue to receive the correct medicines and that all medicines held in the home are properly accounted for. EVIDENCE: Not all residents had a care plan. Those care plans that exist are invariably out of date and no longer accurate, and frequently omit essential aspects of high behavioural and health risk; essential information including appropriate management of aggression and possible deterioration in condition, emergency Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 12 action to be taken by staff, and details of on-going care needs was not stated for a number of residents with special health needs. However, in discussion with the inspector senior care staff demonstrated good understanding of the conditions. All accidents are recorded, but subsequent actions taken to minimise the risk of recurrence are not always recorded; the home does not have a policy and procedure for accidents and does not periodically audit accidents to identify any trends or patterns (e.g. in time, place, person or activity) and subsequently to introduce measures to reduce the risks. Residents are assessed for their ability to manage their own medicines; at the time of inspection a number were doing this. The home has suitable storage facilities for medicines; there are no Controlled Drug recording facilities and to date, these have not been needed. With one exception, staff involved in handling medicines have not received accredited training in this work. Records indicated that medicines had been accurately administered but must be improved to ensure that residents receive correct medicines and doses, and that the home can properly account for all medicines held. Medicine administration records (MARs) did not state the allergy status (to medicines) of each resident, stock balances were not recorded for Temazepam tablets, handwritten amendments to the printed MARs were not signed and dated and there was not a summary of all medicines prescribed for each resident, describing purpose and possible side-effects. A related Immediate Requirement was issued during the inspection. Residents are treated with respect and their privacy and dignity is promoted; staff are kind and considerate, and keen to assist residents. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 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 standard(s) These standards were not assessed during this inspection. EVIDENCE: Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The complaints policy and procedure must be improved to ensure residents have sufficient information and guidance about making complaints, and to whom they can be made. The home has inadequate and frequently inappropriate policies and procedures for the protection of residents from abuse or neglect and in consequence has not always taken correct action to deal with events which have placed residents at risk of harm and has not notified the Commission of these events. EVIDENCE: No complaints against the home have been received or investigated since the last inspection. As stated in the report of the previous inspection, the complaints policy and procedure should be amended to include the telephone number of the Commission, enabling residents to complain directly and easily if they so wish. The policies and procedures relating to understanding and management of abuse are unclear, incomplete and in some aspects, inaccurate. During recent weeks the behaviour of some residents has placed others at risk of harm and injury; the home had not informed Dorset Social Care & Health and the Commission for Social Care Inspection of these events, and had not adhered to nationally established guidance in dealing with these matters. In consequence, other residents have continued to be placed at risk of harm. A related Immediate Requirement was issued during the inspection. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19 & 22 The home is attractive, comfortable and well decorated, providing a pleasant living environment. The communal rooms are suitably decorated and appropriately furnished and the home has a cosy and relaxed atmosphere throughout. The home has not been assessed by an Occupational Therapist or similarly qualified person, to ensure it is suitable to meet the various needs of residents. EVIDENCE: The home is attractively furnished and decorated and subject to continuous improvement. The home has not been assessed by an Occupational Therapist or similarly qualified person to ensure it is suitable to meet the needs of residents; the currently accommodated residents are of varying dependency levels –high, medium and low. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staffing levels are significantly below those recommended by the Department of Health guidance calculation. The home does not provide sufficient care staff at night to safely meet the care needs of all residents throughout each night. Residents think staff are often rushed and under pressure and they do not feel there are always sufficient staff on duty to provide care and promote safety. Recruitment and employment practices do not reliably protect against risks of unsuitable staff being employed. A related Immediate Requirement was issued during the inspection. There is insufficient time for staff to receive formal supervision, appraisal and training. EVIDENCE: The Staffing Forum calculation indicates that, based on the dependency levels of currently accommodated residents, at least 466 care staff hours should be provided each week; during week commencing 4 July 2005 the home provided care staffing of 352 hours indicating a shortfall of 114 hours. At night there is one care worker on duty, with another carer asleep in the home and available on call. Many residents require two staff to attend to them, but because a second carer is not routinely available at night their care is being compromised and a requirement to address this is made in this report. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 17 In conversation with the inspector, and by use of completed Comment Cards, a number of residents expressed concerns about staffing levels. Comments included “the quantity of staff is very lacking…in an afternoon I’d hardly find anybody unless I rang the bell”, “not enough staff…the ones who are here are overworked”. Employment records of a recently employed care worker were not available in the home, being in the safe keeping of the Responsible Person. Employment records of 2 other recently employed care workers were examined. For one there were no references, no evidence of identification, the history of employment was unclear, giving conflicting information and the CRB disclosure had been obtained by a previous employer; no POVA check had been recorded. For the other care worker there were two references but both had been obtained 5 months after the person commenced working in the home. Similarly, the CRB and POVA disclosures had been obtained 6 months after employment commenced. There was incomplete history of employment and insufficient evidence of identity. Although staff work under the continuous supervision of senior carers, there is no process of formal and recorded supervision and appraisal, so individual weaknesses and training needs may not be identified. Residents are not all confident they can receive help when needed; comments made during the inspection included “in an afternoon I’d hardly find anybody unless I rang the bell”. Comment cards returned to the Commission stated “staff too stretched to pay much individual attention”, “staff work very hard but insufficient staffing levels to allow them to interact with residents beyond normal day-to-day contacts (meals etc.), most residents spend long times without social stimulation”. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 & 38 The home has been without a registered manager since September 2004. In consequence, recent events, inadequate recruitment practices, lack of staff safety training, and the frequent absence of planned care have placed residents at risk of harm and injury. The Commission has not received notification of recent events likely to adversely affect the wellbeing or safety of service users. In consequence, risks to residents have been increased. Fire safety equipment is regularly checked and tested but staff have not received fire safety training at required frequencies, so in the event of fire in the home, not all staff may know what action to take to protect residents from harm. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 19 EVIDENCE: The previous registered manager left the homes’ employ during September 2004. Since that time the home has been without a registered manager. The home is at present in the daily charge of care staff who do their best to maintain good standards but are without the necessary experience and knowledge to indefinitely manage the home. Residents are alert to these circumstances. Comments included: “The home is being well run by carers, doing their best under difficult circumstances…(the senior carer) is absolutely excellent, but … has not got the time to do the work…the main thing that is wrong with this place is that it hasn’t got any management…I think if we had a 5 day a week manager who had a grip on it, it’d be a much better place”. Others said that the home had “deteriorated…(due to) the lack of a proper manager…(the senior carer) is doing as much as she can within her limited experience”, “no interest from the top, the management…we have some nice girls but they won’t stay…who’s here to train them?” The home has failed to notify the Commission of 2 recent false fire alarms, both attended as emergencies by Dorset Fire & Rescue Service. The home has also failed to notify the Commission of a number of recent incidents when residents were placed at risk of harm or injury by the behaviour of other residents. The Registered Person has not provided reports to the Commission at the monthly frequency required by the Care Standards Act 2000. The Commission has thereby been unaware of these incidents and in consequence unable to provide staff with necessary guidance and information designed to minimise and properly manage the risks. There are regularly recorded checks and tests of fire safety equipment but records of fire safety training to staff did not reliably indicate that all staff have received training at the required frequencies. For example, a night care worker who should have attended at least 4 fire safety training sessions in the past year was recorded to have attended none since January 2004 Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x 2 x x x x STAFFING Standard No Score 27 1 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 1 1 1 x x 2 1 2 Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement The registered provider must make available a service users guide providing all information necessary for compliance with this Standard. Previous timescale of 31/03/05 not met. Following pre-admission assessment, when the home decides to offer a place to a new resident, they should firstly write to the person stating that they will be able to meet their assessed needs. A comprehensive care plan must be recorded for each resident. As a priority, care records must include details of high risk conditions e.g. diabetes, asthma. The stock balance of Temazepam must be recorded following each administration of the medicine. The home must be able to demonstrate that access to personal records is facilitated for service users in accordance with the Data Protection Act 1998. This requirement is repeated from the previous inspection, timescale not met: 31/03/05 The registered person must be Timescale for action 01/09/05 2. 3&4 14(1)(d) 12/09/05 3. 4. 5. 6. 7 7 9 14 17 13 13 17(1)(b) 01/09/05 18/07/05 11/07/05 01/09/05 7. 18 13(6)&13 01/09/05 Page 22 Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 (7) 8. 18 & 37 37 9. 22 23(2) 10. 29 19 & Schedule 2 11. 12. 29 & 37 29 Schedule 2 8 13. 37 26 able to demonstrate that robust procedures have been implemented for responding to suspicion or evidence of abuse or neglect, in accordance with the Department of Health guidance ‘No Secrets’. Previous timescale of 31/01/05 not met. The registered person must promptly notify the Commission of any event in the home which seriously adversely affects the well-being or safety of any service user. The registered person must ensure that the premises are assessed by a suitably qualified person, including a qualified occupational therapist and that recommendations of the assessment are complied with. Previous timescale of 31/03/05 not met. There must be evidence that the home operates a robust recruitment procedure. New staff must not commence work in the home without evidence of suitable CRB and POVA disclosure. At all times, all records required by regulation must be available in the home for examination. Application for registration as manager must be made to the Commission by a suitably competent person. The Responsible Individual must arrange for the home to be visited at least once each month to inspect the premises, interview, with their consent, residents and staff and must provide to the Commission a written report on the conduct of the home. 11/07/05 01/12/05 11/07/05 11/08/05 01/09/05 11/08/05 Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 23 14. 38 23 (4)(d) There must be recorded evidence that all staff have received fire safety training of appropriate standard at required frequencies. 11/08/05 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. Refer to Standard 8 9 9 Good Practice Recommendations The home should develop and implement a policy and procedure for dealing with accidents, to include periodic audit. The medicine administration records for each resident should clearly state any allergy to medicines, or none known. Handwritten amendments and additions to medicine admnistration records should be signed and dated by the writer, and countersigned by somewhat who has checked the entry for accuracy. All staff involved in handling medicines should receive accredited training in this work. Facilities for the correct recording of Controlled Drugs should be provided. There should be a written summary of all medicines prescribed for each resident, describing purpose and possible side-effects. The telephone number of the Commission should be provided to residents and their representatives in connection with the complaints policy/procedure. This recommendation remains unmet from the previous inspection report. Policies and procedures should be developed and implemented regarding service users financial affairs to preclude staff assisting in the making of or benefiting from service users wills..This recommendation remains unmet from the previous inspection report. The homes policies and procedures for the understanding and management of physical and/or verbal aggression including restraint should be improved to ensure accuracy and provision of appropriate guidance and information. Staffing levels should be reviewed in accordance with the residential forum calculation for the number of care hours D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 24 4. 5. 6. 7. 9 9 9 16 8. 18 9. 18 10. 27 Spetisbury Manor provided. Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole, Dorset BH17 0NF 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 Spetisbury Manor D55 S26768 SPETISBURY MANOR V233307 130605 Stage 4.doc Version 1.30 Page 26 - 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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