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Inspection on 31/10/06 for Sutton Manor Care Home

Also see our care home review for Sutton Manor Care Home for more information

This inspection was carried out on 31st October 2006.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home utilises effective needs assessments and care planning processes to ensure the holistic needs of the service users are identified and met effectively. Service users stated that they are afforded appropriate levels of privacy and dignity at the home at all times. The home provides a varied social activities programme within the home and within the broader community and service users are encouraged to maintain contact with their family and friends. The food provision at the home is wholesome, appealing and balanced and the dining room is safe and fit for purpose. Residents feel safe at the home and believed that any concerns or complaints are listened to, taken seriously and acted upon by the manager and staff at the home. Internally the home provides a safe, well-maintained environment for its service users, which is clean, pleasant and hygienic throughout. Staffing levels at the home are appropriate in meeting the needs of the service users. The home utilises an appropriate recruitment policy, which is adhered to thus ensuring residents are supported and protected. The policies and procedure appertaining to the receipt, storage, administration and disposal of medication is effective in promoting the service users safety.

What has improved since the last inspection?

The home now benefits from a patio area, which can be accessed via newly installed patio doors.

What the care home could do better:

Concerns highlighted at a previous inspection in relation to the mandatory training of staff at the home have not been addressed effectively, which could compromise the safety of service users at the home. The service users consultation process within the home is compromised, as service users meeting are not performed on a regular basis.

CARE HOMES FOR OLDER PEOPLE Sutton Manor Care Home Priestsic Road Sutton In Ashfield Nottinghamshire NG17 2AH Lead Inspector Steve Keeling Key Unannounced Inspection 31st October 2006 9:00 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 Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sutton Manor Care Home Address Priestsic Road Sutton In Ashfield Nottinghamshire NG17 2AH 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) 01623 551215 01623 441150 Ashmere Care Homes Mrs Barbara Ann Guinnane Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Sutton Manor Residential Home is part of the Ashmere Care Group. The home is situated on Priestic Rd Sutton In Ashfield, Nottinghamshire. One of three Care Homes based on the site close to the town centre and community facilities, the home provides 45 beds offering personal care for older people 65 plus. The home provides en suite facilities to the majority of rooms. The accommodation is provided on two floors. The home offers an intermediate care service with 5-10 beds for rehabilitation. The aim of the residential intermediate care scheme is to provide a safe environment within a residential setting for people who would otherwise face unnecessary prolonged hospital stay, inappropriate acute hospital admission or long term care. Through the provision of specialist interventions by a multidisciplinary team individuals are given the opportunity to maximise their potential when carrying out activities of daily living. The home has large garden facilities that are well maintained and easily accessible to the service users. The fees currently charge at the home are £380 per week which includes podiatry services, hairdressing services and daily newspapers. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was performed on 30th October 2006 and was undertaken by one inspector. The main method of inspection was case note tracking, this is a method of randomly selecting service users within the home and discussing with them their expectations and experiences of living within the home environment. The case tracking method also analyses the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the residential care home setting and that their safety and well being is being maintained. On this occasion three service users notes were case tracked. Also as part of the inspection process the inspector informally interviewed two members of staff employed at the home together with a service user’s relative visiting at the time of the inspection. The inspector also performed a partial inspection of the internal environment of the home to further glean the quality of care provided to service users. What the service does well: The home utilises effective needs assessments and care planning processes to ensure the holistic needs of the service users are identified and met effectively. Service users stated that they are afforded appropriate levels of privacy and dignity at the home at all times. The home provides a varied social activities programme within the home and within the broader community and service users are encouraged to maintain contact with their family and friends. The food provision at the home is wholesome, appealing and balanced and the dining room is safe and fit for purpose. Residents feel safe at the home and believed that any concerns or complaints are listened to, taken seriously and acted upon by the manager and staff at the home. Internally the home provides a safe, well-maintained environment for its service users, which is clean, pleasant and hygienic throughout. Staffing levels at the home are appropriate in meeting the needs of the service users. The home utilises an appropriate recruitment policy, which is adhered to thus ensuring residents are supported and protected. The policies and procedure appertaining to the receipt, storage, administration and disposal of medication is effective in promoting the service users safety. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 3 and 6 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. Accurate assessments are performed to ensure that the holistic needs of the service users are identified prior to admission to the home and to the Residential Intermediate Care Scheme (RICs) EVIDENCE: The inspector examined three service users pre-admittance assessments on the day of the inspection. Two service users were permanent residents at the home and one service user was on the Residential Intermediate Care Scheme (RICS). The aim of the RICs scheme is to provide a safe environment in the residential setting for people who would otherwise face unnecessary prolonged hospital stay, inappropriate acute hospital admission or long term care. The case tracked service user on the Residential Intermediate Care Scheme (RICS) had an effective needs assessment performed by members of the multidisciplinary team within the RICs scheme. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 9 The pre-admittance assessments of the two case tracked service users, who were in permanent residency at the home were also detailed in identifying their holistic needs and utilised National Health Service (NHS) and Social Services (SS) assessments when available. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 7, 8, 9 and 10 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. Accurate care plans are formulated at the home, which effectively addresses the identified residential needs of the service users at the home. The service users needs are fully met at the home. Service users are protected by the homes policies and procedures in relation to the management of medicines at the home. Service users are afforded appropriate levels of respect and dignity at all times. EVIDENCE: Three service users care-planning documentation was examined on the day of the inspection. It was evident that the care planning process was effective in meeting the holistic needs of the service users. Care plans evidenced within the three case tracked notes included the following, housing, personal care, oral health, foot care, health and physical wellbeing, domestic assistance, diet, technical aids, social interests and Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 11 hobbies, night care, financial management, sexuality, mobility and dexterity, history of falls, continence, medication management and mental health. The service users care plans were evaluated on a monthly basis or more frequently if required by the service users “key worker” to ensure that any changes in the service users needs are identified and addressed effectively through the care planning process. The care plans were well organised and well presented and the care planning documentation was stored securely to ensure information appertaining to the service users remains confidential. The care planning documentation evidenced that the home utilises an effective risk assessment tool to determine the service users susceptibility to the formation of pressure ulcers. An examination of a service user care plan evidenced that service users who had a high risk of pressure ulcer formation had not had a care plan formulated to specifically address the risk of pressure ulcer formation. It is recommended that the registered person ensure that all service users who are identified as “at risk” of pressure ulcer formation, have a care plan formulated which specifically addresses the identified risk. The home operates an efficient medication policy in relation to the receipt, administration, safekeeping and disposal of medication. To ensure that standards are maintained in relation to medicine management, an effective medication audit process is utilised to ensure the management of medication remains effective. The case tracked service users Medication Administration Record (MAR) were examined at the time of the inspection and it was established that policies in relation to the administration of medicines had been fully adhered to and no concerns were identified. The manager at the home stated that should a service users wish to be independent in the administration of medicines a risk assessment would be initiated. The inspector examined the risk assessment documentation appertaining to the self-administration of medicines. It was evident that the risk assessment process would be effective in determining the safety of service users in relation to self-administration of medicines. An examination of the medication room evidenced that the temperature within the medication fridge had been monitored and recorded on a daily basis as had the temperature of the medication room and were within acceptable parameters. The service users and a visitor to the home spoken with on the day of the inspection stated that services users respect and dignity is maintained at all times. Service users confirmed that staff always knocked on their bedrooms doors before entering and also stated that staff always promoted their privacy and Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 12 dignity when bathing or performing personal care by ensuring that curtains are drawn and doors are closed. The inspector witnessed several interactions between service users and staff at the time of the inspection. It was evident that the staff promotes the principles of respect and dignity at all times and displayed genuine care and consideration towards services users. The manager stated that principles in relation to the promotion of the service users privacy, respect and dignity are initially discussed on induction to the home, an examination of the induction package confirmed respect and dignity is addressed effectively. The member of staff stated that staff always knock on service users doors before entering, determine the service users choice of cloths in the mornings, always respect the service users decisions in relation to dining times and food provision, always promote the service users confidentiality, utilise effective listening skills and always ensure service users concerns and opinions are valued. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 12, 13, 14 and 15 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. The home provides varied social activities within the home and within the broader community. Service users are encouraged to maintain contact with their family and friends. Service users are encouraged to exercise choice and control over their lives. Service users are provided with a wholesome, appealing and balanced diet. EVIDENCE: The manager at the home stated that a varied social activities programme is performed within the home and within the broader community in which the service users can choose to participate in if they wish. Service users spoken with on the day of the inspection together with a relative visiting the home confirmed that a varied social activities programme is provided at the home. An examination of the social activities board displayed in the homes dining room evidenced that the manager had recently arranged a Halloween party for the service users, which included a meal of hot dogs and mushy peas. The service users spoken with stated that they particularly enjoyed the event. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 14 Service users also confirmed that guest entertainers visit the home on a regular basis, which they particularly enjoy. Service users also stated that care staff at then home encourage service users to participate in games such as bingo, dominoes and cards. Service users can also access areas of local interest via a mini bus thus ensuring service users have the choice to interact within the local community. In relation to visitations at the home the manager and a member of staff stated that an open door policy is promoted at the home, in which the friends and relatives of the service users can visit whenever they wish. Service users spoken with also confirmed the open access, as did a visitor to the home. The visitor praised the staff stating that “the staff are very friendly and I feel welcome in the home”. Service users comments were all positive and included “the food is lovely, I can have a drink whenever I wish and a good cooked breakfast is` available for those who wish it”. The service users spoken with confirmed that the food in the home is of good quality, well presented and a choice is always available. Another service users stated that “a choice always made available, the food is fantastic, I can have a drink whenever I want one, I only have to ask”. On the day of the inspection the menu board in the dining room displayed a choice of Shepherd’s pie or Tuna pie followed by a choice of puddings. An examination of the dining room evidenced that the area was well lit, hazard free, well decorated and fit for purpose. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 16 and 18 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. Service users feel confidant that any concerns or complaints will be listened to, taken seriously and acted upon by the manager. Staff at the home have not received effective training in the protection of the vulnerable adult, which could compromise the safety of service users at the home. EVIDENCE: In an attempt to facilitate an effective complaints procedure the manager at Sutton Manor ensures that the complaints procedure is on display within the foyer the home. An examination of the home admission pack also evidenced that service users and their representatives are also provided with a complaints procedure when establishing residency at the home. A case tracked service users stated that she felt safe within the home and should she have any concerns or complaints she would feel confident that the manager would address them effectively and professionally. Another service users stated, “the home is just right I have no concerns or complaints, if I did have a complaint I would discuss it with any members of the staff at the home as they are all approachable and friendly”. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 16 An examination of the complaints book evidenced that the manager at the home documents all complaints thoroughly and that all complaints are addressed effectively within the specified time limits. A member of staff interviewed on the day of the inspection demonstrated an appropriate awareness of issues relating to the protection of the vulnerable adult (POVA). The staff member stated that if suspected abuse was happening she would initially ensure the safety of the service users, discuss her concerns with her line manager and consider contacting Social Services, The Commission for Social Care Inspection, the service users family, advocacy services such as age concern or the Police if necessary. The staff member confirmed that adult protection issues were discussed within her recently attained NVQ 2 qualification in care but also stated that she has not received any formal training in relation to (POVA) whilst in employment at the home. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 19 and 26 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. Sutton Manor provides a safe, well-maintained environment for its residents. The home is clean, pleasant and hygienic throughout. EVIDENCE: A partial inspections of the home evidenced that Sutton Manor continues to provide a clean and well-decorated environment for service users enjoyment. All communal areas were well decorated, appropriately lit and free of obstacles and hazards. All communal areas were maintained to a high standard, as were the communal toilets and bathrooms, the home was odour free throughout. The case tracked service users gave the inspector consent to examine their bedrooms. The bedrooms were found to be personalised, homely and safe. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 18 Window restrictors were in place together with radiator guards. All bedrooms inspected had nurse call buttons strategically placed should the service users require attention whilst in their bedrooms. Service users and visitors to the home praised the high standards of hygiene and cleanliness throughout the home and stated that they have never had any concerns in relation to the internal or external environment of the home. A service user stated, “I am very happy with my room, its always cleaned effectively and is lovely and cosy, the home is spotless at all times, the cleaning staff work very hard “. The inspector was able to have a brief conversation with the domestic staff at the home. It was evident that they were proud of the standard of hygiene throughout the home. The domestic staff stated that they had been in employment for many years and that equipment and cleaning products are always made available to promote the high standard of hygiene at the home. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Standards 27, 28, 29 and 30 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are appropriate in meeting the needs of the service users. The home utilises an appropriate recruitment policy, which is adhered to thus ensuring service users are supported and protected. The staff training matrix evidenced that staff at the home have not received all the mandatory training to do their jobs effectively thus compromising the safety of service. EVIDENCE: Staff employed at the home is sufficient numbers to meet the residential needs of the service users. On the day of the inspection 40 residents were accommodated at the home. Four carers and one senior carer were on duty throughout the morning, throughout the afternoon three carers and one senior carer were on duty and two carers plus one senior carer covered the night period. A senior carer stated that she works five 7-hour shifts per week, never feels intimidated to work additional shifts to cover absenteeism. The senior carer also stated that the care staff at the home are respected by the manager and they feel valued. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 20 An examination of staff files and a discussion with the manager evidenced that the homes recruitment policies are followed thus ensuring the safety of the service users. The recruitment documentation of the last two members of staff employed at the home was checked and found to be satisfactory. Both staff members had undergone appropriate Protection of Vulnerable Adult checks together with Criminal Record Bureau (CRB) checks and had provided two written satisfactory references. The homes documentation relating to the recruitment process was well organised and clear. All new staff members received an appropriate induction programme that normally takes six weeks to complete. The inspector was provided with an example of the induction format given to all newly appointed staff members. The induction process is comprehensive and provides appropriate information appertaining to all care provisions within the home. The induction documentation evidenced topics such as principles of care, understanding the organisation and the role of the worker, understanding the needs of the service user group, and maintaining safety at work. In ensuring that service users are safe and a high quality service is provided all staff employed at the home should receive mandatory training appropriate to the roles they are to undertake. An examination of the staff training documentation and a discussion with the manager at the home confirmed that the training opportunities were not appropriate in ensuring the safety of service users and staff. For example, training events in relation to the Protection of Vulnerable Adults have not been provided to staff. The manager at the home confirmed the shortfall. An examination of the training records evidenced that only 14 of the workforce had received training in Moving and handling, 21 in relation to First Aid, 32 in relation to Health and Safety, 32 in relation to Infection Control. No staff had received training in relation to the protection of the vulnerable adult although the subject is discussed within NVQ training which 36 of the staff had attained NVQ level 2 or above. The ensure the safety of service users at the home, the registered person will be required to analyse all the staff training documentation to determine the training needs of the entire workforce at the home so that appropriate training opportunities can be provided thus ensuring the safety of the service users at all times. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 31, 33, 35 and 38 were inspected on this occasion. This judgement has been made using available evidence including a visit to this service. The manager at Sutton Manor is professional, fit to be in charge, of good character and is able to discharge her responsibilities fully. The service users consultation process within the home is compromised, as service users meeting are not performed on a regular basis. Service users financial interests are now safeguarded by the policies utilised at Sutton Manor. The manager at Sutton Manor Residential Home ensures that the health, safety and welfare of service users and staff are promoted and protected Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager of the home has been in post since December 2004. Having gained her a City and Guilds qualification in Advanced Management and Care in 1997 and in possession of the D32 and D33 NVQ assessors award it was evident the manager has the necessary experience and educational abilities to effectively perform the manager’s role at Sutton Manor residential home. The manager continues to maintain effective evaluation and care planning documentation appertaining to the needs of the service users and all documentation is stored securely to protect service users confidentiality. Service users stated that they felt confident in the manager’s abilities to manage the home in a professional manner whilst promoting a relaxed environment. At a previous inspection it was evidenced that the manager, in attempting to ensure that the home is run in the best interests of the service users, had initiated service user meetings. The intentions of the meetings were to promote the communication process between the service users and the management within the home. An examination of the minutes of the last meeting evidenced that the meeting took place in January 2006 and another meeting had not taken place since that time. To ensure that service uses have an effective forum to discuss issues relating to all aspects care provision at the home it is recommended that the registered provided performs the service user meeting on a more regular basis. At a previous inspection it was evidenced that the service users monies are effectively managed and the manager ensures that separate written records of all monitory transactions are maintained. Items such as podiatry services, hairdressing and newspapers are included in the fees charged at the home. Since the last inspection a substantial amount of money (the serviced users social fund) had been stolen from the safe at the home. Although the manager contacted the police and an investigation was performed the culprit has not been identified. The manager stated that the money had not been reimbursed to the service users fund and the homes insurance policy did not cover the theft. The Commission for Social Care Inspection will pursuer the matter further with the registered person to determine that service users finances are safeguarded at the home. The ensure the future safe keeping of the service users fund the manager has now purchased another safe in which the service users fund is stored. Only the manager has access to the safe thus protecting the service users fund in the future. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 Page 23 In determining that the health and safety of service users is protected the inspector examined a range of Health and Safety documentation on the day of the inspection. The information evidenced effective servicing is carried out by approved technicians in relation to lift servicing, gas servicing, mobility equipment servicing, portable appliance testing, Legionella control measures, Fire alarm tests and servicing, weekly Emergency Lighting tests and Environmental Health visit. Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 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 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Sutton Manor Care Home DS0000008807.V316570.R01.S.doc Version 5.2 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 OP30 Regulation 18 (1) (a) Requirement Timescale for action 31/01/07 2 OP30 18 The registered person shall ensure that all persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. Outstanding from 31/01/06 The registered person shall 16/11/06 provide the Commission for Social Care Inspection with evidence of the training events booked to address the staff training shortfalls identified within the inspection report. 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 Refer to Standard OP33 Good Practice Recommendations The registered person should ensure that an effective consultation process is initiated based on seeking the views of service users to measure success in meeting the aims, objectives and statement of purpose of the home. The registered person must ensure that all service users who are identified as “at risk” of pressure ulcer formation, have a care plan formulated which specifically addresses the identified risk. DS0000008807.V316570.R01.S.doc Version 5.2 Page 26 2 OP7 Sutton Manor Care Home Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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