Inspection on 10/09/07 for The Manor House

This inspection was carried out on 10th September 2007.

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

The Manor House 31/03/09

The Manor House 02/02/07

The Manor House 14/12/05

The Manor House 25/11/05

The Manor House 13/09/04

The Manor House 06/04/04

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

CARE HOMES FOR OLDER PEOPLE The Manor House The Manor House 6 Bawnmore Road Bilton Rugby Warwickshire CV22 7QH Lead Inspector Michelle McCarthy Key Unannounced Inspection 10th September 2007 09:45 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 The Manor House DS0000032248.V347853.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. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Address The Manor House 6 Bawnmore Road Bilton Rugby Warwickshire CV22 7QH 01788 814734 01788 814734 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) Pinnacle Care Ltd Caroline Margaret Rose Irvine Care Home 26 Category(ies) of Dementia - over 65 years of age (26) registration, with number of places The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2007 Brief Description of the Service: The Manor House is a mature building with parts dating back to the 16th Century, and is set in its own grounds, adjacent to the village green, in Bilton, Rugby. The Manor House was converted from a private dwelling into a care home in 1985. The Manor is registered to take 26 older people with dementia. The Manor House has twenty-two single bedrooms, twenty-one of which have en-suite facilities. One of the two double rooms also has en-suite facilities. There are two communal bathrooms and four communal toilets. The home has three large communal lounges with south facing gardens. The accommodation is over two floors reached via two passenger lifts. The local shops and amenities are a 2-minute walk away. On the day of this inspection visit there was no written information available about the costs of living in this home. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection visit which addresses all essential aspects of operating a care home. This type of inspection seeks to establish evidence showing continued safety and positive outcomes for people living in the home. This report uses information and evidence gathered during the key inspection process which involves a visit to the home and looking at a range of information. This includes the service history for the home and inspection activity, notifications made by the home, information shared from other agencies and the general public and a number of case files. The visit to the home was made on 10th September 2007 between 9.45am and 6.45pm. 22 people were living in the home on the day of the visit. It was the assessment of the home manager that the majority of people living in the home had medium or high dependency care needs. Documentation maintained in the home was examined including staff files and training records, policies and procedures and records maintaining safe working practices. A tour of the building and several bedrooms was made. The systems for the management of medication were also examined. The inspector had the opportunity to meet most of the residents by visiting them in their rooms, spending time in the communal lounges and talking to several of them about their experience of the home. There was an opportunity to chat socially when the inspector joined residents for their midday meal. General conversation was held with others, along with observation of working practices and staff interaction with the people living in the home. The home manager was present throughout the day. The inspector also spoke to several care staff, the cook and a district nurse who was visiting a resident. The care of three people living in the home was identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence of the care provided is matched to outcomes for the people using the service. The manager completed and returned an Annual Quality Assurance Audit before the inspection visit. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Care plans must be available for each of the identified needs of people living in the home and contain details of the actions required to meet each need. Care plans must be reviewed at least monthly or when there is a change in need. This is to make sure that people get the care they need. Systems must be in place to identify any risk to the health or well being of people living in the home and must include details of how any identified risk The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 7 can be reduced. This must include the risk of developing pressure sores and falls. This is to make sure that risks to the health or well being of residents are identified and reduced. Arrangements must be made for people living in the home to have access to dental and optical services. This is to make sure that people living in the home have access to healthcare. Arrangements must be made to make sure that medicines prescribed for people living in the home are given accurately. This is to prevent the risk of harm from medication administration errors. The complaints policy must be reviewed and made accessible to residents and their visitors. This is to make sure that people have written information about what to do if they have a complaint or concern. This is outstanding from the last inspection. Policies and procedures related to the recognition of abuse, actions to take in the event of abuse and whistle blowing must be reviewed, updated and reflect the practice by for the organisation and local social services. Policies and procedures must be accessible to staff. This is to make sure that staff have information about how to respond to suspicion or allegation of abuse. This is outstanding from the last inspection. Systems must be in place to ensure the effective maintenance of equipment and services in the home and records should be available for inspection. This is to promote the safety of people in the home. 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. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 was assessed. Quality in this outcome area is good. People who are considering moving into the home benefit from having their care needs assessed so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The case files of two people identified for case tracking were examined to assess the pre-admission assessment process. These people were admitted to the home after the last key inspection. The manager said that it was usual practice for a senior member of staff to visit people who are considering moving into the home to undertake an assessment of their needs and abilities. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 10 Each of the files examined contained information about all of the person’s needs and abilities and confirms that the home can meet their needs. Files also contained pre-admission information provided by professional health and social care agencies. Information gathered about the needs and abilities of people living in the home is used to develop care plans to meet these needs. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is adequate. People living in the home are treated respectfully. Their personal care needs are met but the care planning process is disorganised which could lead to an oversight of care. Access to other health professionals is sometimes limited and medicines are not always administered accurately which could leave residents at risk of harm. This judgement has been made using available evidence including a visit to this service.. EVIDENCE: It was evident from observation that the personal care needs of people living in the home are met residents are provided with a good quality of life. People living in the home at this inspection visit were observed to look well and happy and are supported to maintain their abilities. They looked well cared for and were clean, their hair had been combed or ‘dressed’ and nails were trimmed The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 12 and clean. They were well presented and wore clothes that were suited to the time of year. One resident said, ‘The care is very good. It’s better than the last care home I lived in.’ Three people were identified for case tracking. Each person had a care plan, daily day and night time records and monitoring records. Care plans were generally based on information secured during the initial care needs assessment. The ethos of the home is to build on the strengths and abilities of each individual. Each case file contained details of the strengths and abilities of the person and identified some of their needs. However, care plans do not consistently describe the actions staff need to take to meet each individual need. There are three different formats currently in use for care planning. Information about peoples’ needs and the actions required to meet them is generally available but is not easily accessible because it is mixed up and often repeated. Part of the care plan is kept in a locked medication room which means they are not easily accessible to staff; another part of the care plan is kept in residents’ bedrooms. The inspector was unable to locate the records in the bedroom of one resident. There is no evidence of short term care plans. For example, one person was injured following an altercation with another resident. A care plan was not developed to address the need for the protection of the person or to address their anxieties or fears. There is no evidence of regular monthly review, but evidence of ‘ad hoc’ review. This leaves residents at risk of not having their needs met if staff fail to identify and record a new or changed need. A system should be developed and implemented to review care plans at least once a month to reflect changing needs and current objectives for health and personal care. The home uses risk assessment tools to monitor each person’s risk of developing pressure sores, poor nutrition and moving and handling. One case file contained a risk assessment for falls. However, care plans are not always developed to address risks identified. For example, one person was identified as having a medium risk of developing pressure sores. The home’s own procedures state that this level of risk requires staff to involve the community nursing service for advice about prevention of pressure sores and to monitor pressure areas daily and report changes. There was no evidence that these actions had been taken. There is evidence in some case files of appropriate referral to the GP; for example, one person was referred to the GP when staff identified a change in The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 13 their conscious level and ability. The GP diagnosed a transient ischaemic attack (TIA or ‘mini-stroke’). However, there was no evidence in the case files of one person of ever having a review with GP even after their discharge from hospital following an injury. The manager told us that none of the people living in the home currently have pressure sores. The district nurse visits one person who recently had a pressure sore but has now healed. The inspector spoke to the visiting district nurse who said, ‘Staff appear to follow the instructions we leave because the outcomes for residents are good.’ Access to other healthcare professionals such dentist and optician are limited. There have been no dental referrals or check ups offered to residents since October 2006. The manager discussed that the optician no longer makes regular check ups because relatives complained about the cost of providing new spectacles. Arrangements must be made for people living in the home to have access to dental and optical services. The cost of any treatment should then be discussed with the resident and their family so they can choose whether they want to pay for the treatment. The systems for the safe management of residents’ medication were examined. Medicines are stored in locked cupboards within a small locked storeroom. The manager and staff member responsible for the administration of medicines hold keys to the room. A monitored dosage (‘blister packed’) system is used. A very small fridge is available with daily recordings of the temperature. Records of the fridge temperatures show the temperature is consistently above 5°C with no evidence of action taken to ensure the temperature was within recommended limits The inspector recommends the review of the facilities for storing medication requiring refrigeration to ensure that medicines stored at the correct temperature to ensure their stability. Audits of the medication of the people involved in case tracking were undertaken and discrepancies were observed suggesting that medicines are not administered accurately. For example, • 84 haloperidol tablets were dispensed for one person. 34 tablets were signed as having been administered which should have left 50 tablets. However, 54 tablets were left. This suggests that 4 tablets were signed for but not administered. 46 Adcal tablets were dispensed for one person. 12 tablets were signed as having been administered which should have left 34 tablets. However, DS0000032248.V347853.R01.S.doc Version 5.2 Page 14 • The Manor House 35 tablets were left. This suggests that 1 tablet was signed for but not administered. Arrangements must be made to make sure that medicines prescribed for people living in the home are given accurately to prevent the risk of harm from medication administration errors. People living in the home were observed to be treated with respect and their dignity maintained; for example, personal care was provided in private and residents were spoken to respectfully. During observation of working practice it was evident that staff are knowledgeable about the likes and dislikes of people living in the home and were kind, caring and attentive towards them. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. People living in the home are supported to maintain their independence and enduring interests which enhances their quality of life. Mealtimes are celebrated as a social occasion and residents benefit from a varied and nutritious choice of food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an ethos of building on a person’s strengths and abilities. This is reflected in the case files of each person where a ‘life history’, interests, important relationships and personal preferences are recorded to assist staff in providing ‘person centred’ care. The home does not have a planned programme of activities but staff support people living in the home to participate in activities and plan how to spend their time on a day to day basis, depending on their preferences for that day. On the day of this unannounced visit, a musical entertainer provided a sing-aThe Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 16 long enjoyed by many residents in the afternoon. Residents were supported by staff who joined them in the lounge and participated in the sing-song. There is a strong feeling of community and sense of belonging. Groups of residents interacted with staff and each other and were aware of each others needs and preferences. It was evident that friendships had developed between residents. Staff spoken to were familiar with the preferences of residents and the type of activities that might engage and stimulate each individual. The home has an open visiting policy. People are encouraged to maintain links with their family, friends and local community. The inspector joined residents at 12.30pm for their midday meal. Staff invited residents to have their meal in the pleasant surroundings of the dining room but some chose to remain in the lounge area or their own rooms. Tables were beautifully set with linen tablecloths and slip cloths which lent a ‘restaurant type experience’ to the social occasion of people coming together to enjoy their meal. 15 people attended the dining room for lunch. Residents were offered a starter of melon followed by a choice from Sausages, veggie burger or curry accompanied by cabbage, cauliflower, mashed potatoes or chips and gravy. Dessert was a choice of apricot crumble and custard or ice cream vienetta. Staff offered each resident a choice of meal at the table; those people who found it difficult to choose were assisted by staff who brought the meal to them as a visual prompt. Food was plentiful and ‘seconds’ were offered. When residents had been served, staff took their choice of meal and ate with the residents The meal was served from a heated trolley from the kitchen and was beautifully presented, nutritious and tasty. Discreet and sensitive assistance was given to residents who needed help eating their meal. Residents made positive comments about the food they were offered in the home; one person said, ‘the food’s always good’. Another person told us, ‘I have toast and marmalade for my breakfast but you can have bacon or egg if you want. Then there is High Tea about five or five thirty in the evening.’ The most recent Environmental Health Officer’s inspection of the home’s kitchen awarded a Gold Standard for Food Hygiene in January 2007. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. People living in the home are able to approach the manager with their concerns and feel confident that they are acted upon. Policies relating to protection do not give staff clear direction about how to respond to an allegation or suspicion of abuse. This does not safeguard people living in the home from the risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were two different complaints policies available in the home on the day of this inspection visit giving conflicting advice on what to do in the event of having a complaint or concern. Some of the contact details in the policies were out of date. The complaints policy needs to be reviewed and made accessible to residents and their visitors so that people have written information about what to do if they have a complaint or concern. In practice people are encouraged to raise their concerns with the manager or senior care staff. On two occasions during the inspection visit residents came into the manager’s office to talk about their concerns which demonstrates that residents feel they can approach the manager. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 18 The home maintains a record of complaints and have recorded none since the last key inspection. This could be enhanced by recording verbal concerns received so that the home can actively demonstrate how they respond to the concerns of people living in the home. We have received two complaints about this service since the last key inspection. One complaint raised concerns about the staffing complement in the home and is addressed in the ‘Staffing’ section of this report. The second complaint raised concerns about the safe management of medication in the home. This was assessed in the ‘Health and Personal Care’ section of this report. Since the last Key Inspection there has been one referral for investigation under Adult Protection Procedures in response to information shared about an allegation of possible abuse. The concerns raised related to a resident sustaining an injury from another resident. Examination of records showed that a care plan was not developed to address the need for the protection of the person or to address their anxieties or fears. Discussion with the manager evidenced that she was familiar with local Adult Protection Procedures and how to refer allegations of abuse. Staff training records show that the manager has undertaken abuse awareness training on an individual basis for staff. A recently recruited member of care staff was able to discuss an appropriate response to a suspicion or allegation of abuse. The home’s policies and procedures regarding Adult protection are disorganised and not accessible to staff. These policies need to be reviewed and made accessible to staff so they have clear instructions about how to respond to suspicion or allegation of abuse, including how to make a referral under local joint agency guidelines. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is good. The home is generally well maintained providing a safe, attractive, homely and clean place for people to live in and enjoy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean, bright and tidy and no unpleasant odours were noticed. A homely feel is achieved in the large communal lounge by placing chairs and furniture in a way that encourages people to interact. Residents ‘pottered’ about the home freely making use of all the communal areas while others sat and enjoyed passing the time of day with others as they went by. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 20 The home has two large lounge areas leading into one another; both these areas were pleasant and clean with a variety of seating to suit all residents. There is also a large area between the second lounge and dining are this has an attractive fireplace and suitable seating. The dining room large and bright and very welcoming; it has a ‘restaurant like’ feel to it. The AQAA informs that in the last year ‘some of the bedrooms have been redecorated’. The bedrooms of three people case tracked were viewed. Rooms were pleasantly furnished and decorated creating an environment where residents can feel comfortable. It was evident that residents are encouraged to personalise their rooms with their own items such as photographs or soft furnishings. Each room looked as though it ‘belonged’ to the person living in it. Specialist equipment, including beds, assisted baths, pressure relieving mattresses and hoists are available to support meeting the individual needs of residents. Systems are in place for the management of dirty laundry. Protective clothing such as plastic gloves and aprons were available and arrangements are in place for the disposal of waste. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is good. There are sufficient numbers of staff on duty to meet the needs of people living in the home and training is provided to make sure people are cared for by competent staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing complement for the home has been reviewed and has improved since the last key inspection. The manager confirmed that the usual staffing complement for the home is: 7.30am – 2.30pm 2.30pm – 9.30pm 9.30pm – 7.30am The Manor House 4 Care Staff 3 Care Staff 2 Care staff (who are awake throughout the night) DS0000032248.V347853.R01.S.doc Version 5.2 Page 22 The manager’s hours are supernumerary but she occasionally works ‘on the floor’ as a carer to cover eventualities such as annual leave or absence due to sickness. There is a member of catering staff in the kitchen between 8am and 2pm each day to prepare breakfast and the main midday meal. Kitchen staff prepare the evening meal but it is heated and served by care staff. The home has one person undertaking cleaning duties between 11am and 4pm during the week; there are no cleaning staff on duty at the weekends. Care staff undertake laundry duties. The home does not employ administrative staff but has support from the organisation’s Head Office for training, payroll and wages and recruitment. Two weeks of the home’s duty rota between 1st and 21st September 2007 was examined and demonstrated that the staffing levels set by the home (in the table above) are usually achieved. The home does not use agency staff to cover holidays or unplanned absence such as sickness but relies on permanent staff working overtime. This means that people living in the home have some continuity and are cared for by staff that are familiar with their needs. The manager said that residents had benefited from an increase in the number of staff on duty. It is evident from observation that the personal care needs of residents are met. However, the service is unable to demonstrate that there is a system in place to ensure that the needs of residents are kept under review when deciding the number of staff needed. Staff were observed to have good interactions with the people living in the home; residents were at ease asking for assistance and making requests. It was evident from observation that staff were knowledgeable about the needs of the people they were caring for and gave sensitive care and support. Comments from residents about staff included; • ‘Sometimes in the morning or evening they take longer to answer the bell.’ • ‘They never get cross or angry.’ A visiting district nurse commented ‘Staff seem to have too much to do.’ One recently recruited member of care staff said they felt ‘there were enough staff on duty to get everything done.’ And ‘we do a good job’. Three of the 16 care staff employed in the home have a National Vocational Qualification in Care (NVQ) at level 2 which, at 19 , falls well below the National Minimum Standard for 50 of staff to be qualified. However, a further ten members of care staff are currently working towards this award which should mean that people living in the home are cared for by competent staff. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 23 The personnel files of two recently recruited staff were examined and both contained evidence that Criminal Record Bureau (CRB) had been applied for, satisfactory Protection of Vulnerable Adult (PoVA First) checks were obtained and satisfactory references received before new staff members started working in the home. These robust recruitment practices should safeguard people living in the home from the possibility of abuse. Staff training records demonstrate that staff receive training in Abuse Awareness, Fire Safety, First Aid, Food Hygiene, Health and Safety, infection control and medication. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33 and 38 were assessed. Quality in this outcome area is good. The home is managed by a competent and qualified person to make sure the service is run in the best interests of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post since February 2007 and was registered by us in July 2007. She is qualified to NVQ level 3 in Care and has completed the Registered Manager’s Award (NVQ Level 4). She is experienced in the care of older people and dementia care. The manager provides effective leadership and direction and staff feel supported. A visiting district nurse told the The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 25 inspector, ‘Things are much better organised since the new manager arrived. Care staff seem more settled and seem to have better guidance.’ A residents’ survey was undertaken in August 2007. The manager said she was currently collating the response so that an action plan could be developed to target areas for improvement. Audits of medication are carried out monthly along with other audits of the home. Daily room audits are carried out and any repairs are recorded in the maintenance book. The maintenance person on completion of the work signs this. Although there are audits carried out in the home, there is no clear indication what is done to improve areas and the time scale required. The manager and provider must be able to demonstrate that there is a regular review of the quality of care and services being provided and the results of any quality exercise are published in the home with details of actions taken to address any concerns raised. The service does not hold service users’ personal monies or valuables for safe keeping so standard 35 is not applicable and was not assessed. Service users are invoiced for additional costs such as hairdressing or chiropody. A sample of service and maintenance records were examined and provided evidence that • the Fixed Electrical Installation Certificate (‘5 year electrical check’) was issued in August 2003 with a recommendation that it should be done again in 12 months. There is no evidence that this has been done. • labels on hoists indicated that they had been checked and service in April 2007 • hot water outlet temperatures are recorded monthly. Some were noted to exceed recommended limits but there was no evidence of any action taken to resolve this. • labels on electrical appliances indicated that Electrical Portable Appliance Testing (PAT) was completed in 2006 and were due again in August 2007. The provider and manager must make sure that there are systems for maintaining equipment and services to the home to promote the safety of people in the home. The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 26 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 27 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 Requirement Care plans must be available for each of the identified needs of people living in the home and contain details of the actions required to meet each need. Care plans must be reviewed at least monthly or when there is a change in need. This is to make sure that people get the care they need. Systems must be in place to identify any risk to the health or well being of people living in the home and must include details of how any identified risk can be reduced. This must include the risk of developing pressure sores and falls. This is to make sure that risks to the health or well being of residents are identified and reduced. Arrangements must be made for people living in the home to have access to healthcare DS0000032248.V347853.R01.S.doc Timescale for action 15/11/07 2 OP8 12 15/11/07 3 OP8 12 15/11/07 The Manor House Version 5.2 Page 28 professionals including dental and optical services. This is to make sure that people living in the home have access to healthcare. Arrangements must be made to 15/11/07 make sure that medicines prescribed for people living in the home are given accurately. This is to prevent the risk of harm from medication administration errors. Policies and procedures related to the recognition of abuse, actions to take in the event of abuse and whistle blowing must be reviewed, updated and reflect the practice of the organisation and local social services. Policies and procedures must be accessible to staff. This is to make sure that staff have information about how to respond to suspicion or allegation of abuse This is outstanding from the last inspection. The date for compliance was 31/03/07 6 OP38 23, 13 Systems must be in place to 15/11/07 ensure the effective maintenance of equipment and services in the home and records should be available for inspection. This is promote the safety of people in the home. 4 OP9 13(2) 5 OP18 13(6) 15/11/07 The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP9 OP16 Good Practice Recommendations The care planning process should be reviewed and one care plan format used so that information is organised and easily accessible by staff. The facilities for storing medication requiring refrigeration should be reviewed to ensure that medicines stored at the correct temperature to ensure their stability. The complaints policy should be reviewed and made accessible to residents and their visitors. This is to make sure that people have written information about what to do if they have a complaint or concern. A system should be implemented to make sure that the numbers of staff required to meet the needs of residents are available on duty at all times. The service should be able to demonstrate that the needs of residents are considered when deciding the number of staff required. This is to ensure that the needs of people living in the home are consistently met in a way that is acceptable to them. The service should be able to demonstrate that 50 of care staff have a National Vocational Qualification in Care at level 2 or equivalent. This is to ensure that people living in the home are cared for by competent staff. The service should be able to demonstrate the review of working practices and quality of care delivered to people living in the home. This should ensure that the home is run in the best interests of people living in the home. 4 OP27 5 OP28 6 OP33 The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Manor House DS0000032248.V347853.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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