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Inspection on 14/03/07 for The Manor House

Also see our care home review for The Manor House for more information

This inspection was carried out on 14th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 management of the home is excellent and service users are very satisfied with the care provided. The ethos of the home promotes service users` wellbeing by recognising their rights to independence and autonomy, for example, to retain their own medication. The service users described the staff as being very kind, caring, attentive and respectful. They said that living in The Manor House is "very good" and "a lovely, friendly place". Staff were described as being "fabulous" and "marvellous" and Kathy Daw, the Registered Manager, was described as a "lovely, kind and thoughtful person". Service users said that the meals are very good. They are informed about menus in advance but have the opportunity to change their minds at short notice if they decide they would prefer something else. Staff retention is excellent and there is a very low turnover of staff. This provides the service users with consistency of care and a sense of security because they know all the staff members.

What has improved since the last inspection?

The home continues to provide an excellent quality of care to the service users and the management and staff team are always looking for ways to improve the service offered. All bathroom and toilet doors have been fitted with locks that can be opened from the outside by staff in an emergency and redecoration is ongoing. A new computer system has been installed that links all the homes in the organisation. In the first instance this will be used for administrative purposes and will progress to data relating to service users, such as care plans.

What the care home could do better:

The refrigerator used to store medicines should only be accessible by staff members to ensure the safety of service users and the security of the medication. Locks should be fitted to all bedroom doors that are suited to service users` capabilities and accessible to staff in emergencies. This is so that service users can have privacy if they wish to and belongings can be kept secure should service users be away from the home for any reason. The quality assurance system should be developed to include an annual internal audit of all the services and facilities in the home to confirm that everything is in good working order, documentation is up to date and the home is run in the best interests of service users. The service could also be improved if the medication administration records give clear reasons and explanations for the reason why, occasionally, prescribed medication is not given to, or declined by, service users.

CARE HOMES FOR OLDER PEOPLE The Manor House 135 Looseleigh Lane Derriford Plymouth Devon PL6 5JE Lead Inspector Antonia Reynolds Unannounced Inspection 14th March 2007 10:55 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 DS0000060572.V327767.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 DS0000060572.V327767.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Address 135 Looseleigh Lane Derriford Plymouth Devon PL6 5JE 01752 778280 01572 776628 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) Welling Ltd Mrs Kathryn Margaret Daw Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: The Manor House is a care home providing personal care and accommodation for thirty older people over the age of 65. The home does not provide intermediate care. The home is privately owned by Welling Ltd, the directors also own other care homes in the South West of England, and the Responsible Individual is Alan Beale. The fee levels are between £278 and £385 per week. Information about the home and copies of inspection reports can be obtained from the Registered Manager, Kathy Daw. The Manor House has been a care home for many years and was purchased by the present owners in 2004. It is located in the Derriford area of Plymouth, close to the hospital, transport routes and other amenities. The home consists of a detached two-storey house with a two-storey extension and has been adapted, to accommodate service users who may have mobility difficulties, with ramps and a shaft lift. Twenty-eight bedrooms are single: sixteen on the ground floor and twelve on the 1st floor. There is one shared room on the 1st floor. Seventeen bedrooms have en suite toilets and bathing, showering and toilet facilities are available on each floor, close to bedrooms and communal rooms. There are lounge and dining rooms on the ground floor, as well as a smaller lounge with a dining table. There is a call bell system installed throughout the home. The home has a large garden, with flower beds and lawn, which is accessible by all the service users. There is parking space at the front of the home and on street parking is available nearby. The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of an unannounced visit between 10.55am and 3.30pm on Wednesday, 14th March 2007 and a further visit on Thursday, 22nd March 2007 between 11.30am and 12.50pm. The Registered Manager, Kathy Daw, was present throughout both visits and the Responsible Individual, Alan Beale, was also available for consultation during the first visit. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. A pre-inspection questionnaire had been completed by the Registered Manager, which contained information relevant to the inspection. Sixteen of the service users were observed during the visit, seven of whom were spoken with at length. Comments were sought from people visiting the home and these included a friend of a service user. Survey forms were sent to ten relatives and six were returned. Six staff members were spoken with during the visit and others were observed in the course of their normal duties. Survey forms were sent to eight staff members but none were returned. Three survey forms were sent to health and social care professionals and two were returned. What the service does well: What has improved since the last inspection? The home continues to provide an excellent quality of care to the service users and the management and staff team are always looking for ways to improve The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 6 the service offered. All bathroom and toilet doors have been fitted with locks that can be opened from the outside by staff in an emergency and redecoration is ongoing. A new computer system has been installed that links all the homes in the organisation. In the first instance this will be used for administrative purposes and will progress to data relating to service users, such as care plans. 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. The Manor House DS0000060572.V327767.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 The Manor House DS0000060572.V327767.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): Standards 1, 2, 3, 4 and 5 Quality in this outcome area is good. Thorough and comprehensive procedures prior to admission ensure that service users and their relatives can be confident that their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre-admission assessment process ensures that the needs of prospective service users are identified. Service users and their relatives are welcome to visit the home prior to admission to meet other service users, staff and have a look around the home. Discussions with service users and the Registered Manager confirmed that each person has a copy of the home’s Statement of Purpose and Service User Guide, so that they know what services the home provides. These documents are available for prospective service users, and/or relatives/representatives, to assist them with making a decision about whether this is the care home they wish to live in. Service users and the Registered Manager confirmed that service users who are privately funded have contracts The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 9 with the home. Discussions with service users, staff and the Registered Manager, as well as observation, show that staff are aware of the needs of the service users. The home does not provide intermediate care. The Manor House DS0000060572.V327767.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): Standards 7, 8, 9 and 10 Quality in this outcome area is good. Service users can be confident that they will be treated with respect and that personal and health care needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users’ files contained care plans and risk assessments relating to health and personal care needs that are regularly reviewed. Discussion with service users, staff and the Registered Manager, as well as observation and information from relatives, confirmed that personal care is maintained, service users can bathe/shower when they choose to and are encouraged to be as independent as possible. Service users said that the call bell is always answered promptly by staff. Discussions with service users and the Registered Manager showed that service users have access to health care services such as doctors, district nurses, physiotherapists, opticians, chiropodists, dentists, and dieticians, as well as any other relevant professionals when required. A copy of each service user’s care plan is kept in their bedrooms so that staff know The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 11 what assistance is needed and service users and their relatives know what care should be provided. Service users said that they are treated with the utmost respect and dignity and their right to privacy is upheld. Discussions with staff members, comments received from a health care professional, as well as observation, confirmed that staff are fully aware of the need to treat service users with respect and ensure that privacy and dignity is maintained. Staff were observed always knocking on doors before entering private rooms. The home has a pay ‘phone in the ground floor hallway and a portable telephone that service users may use for private ‘phone calls. Service users may also have a private telephone installed in bedrooms at their own expense. Service users said that they are very well looked after by staff who are kind, caring and helpful. Staff were observed treating all the service users with kindness, consideration and respect. Information from relatives and a social care professional also expressed satisfaction with the care being provided. One relative commented that the general care “is excellent at all times.” With regard to medication, the home’s policy encourages service users to be self-medicating and keep their own medication in their rooms, subject to risk assessment. Service users confirmed that they could keep their own medication if they wished to and are provided with lockable space in their rooms to keep it. Where medication is administered by staff, it is stored securely and a monitored dosage system is used for the majority of medicines. The home has a small refrigerator specifically for storing medicines that need to be kept at low temperatures but this is kept in an office that is usually open and the refrigerator does not have a lock on the door, therefore anyone has access to the medication stored in there. The home has a list of homely remedies that they may use for service users if required. The medication administration records contain a photograph of each service user and records are kept of the receipt and disposal of medicines. The records were not as clear as they could be regarding medication that was not always required by service users, for example, an ‘X’ was inserted when medication had not been given and there was no explanation as to why it had not been given. The Registered Manager confirmed that she would address this immediately. Only designated trained staff administer medication. The practices were described and demonstrated by a member of staff and these were satisfactory. The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. The routines in the home are relaxed, relatives and friends can be confident that they are welcomed and social activities are arranged. Dietary needs of service users are well catered for with a balanced and varied selection of food that meets service users’ tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are very positive about the lifestyle at The Manor House. They said that they choose where they spend their day, the times they get up and go to bed and when they want to have a bath/shower. They confirmed that visitors are welcome at any time and they particularly enjoy the interaction and conversation with staff. Visitors spoken to said they were free to visit when they wished and were always welcomed by friendly staff. Service users said they enjoyed the activities when they occur however three relatives commented that it would be beneficial if social activities and trips out could be increased to improve stimulation. Various activities take place in the home, such as bingo, movement to music, musical entertainments, slide shows The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 13 and reminiscence. Coach trips are arranged occasionally to local places of interest and for sightseeing and service users are also supported to visit a pub or to go shopping. Some service users go out regularly with their families and friends. All the service users said they liked the food and that anything they asked for is provided. Comments received from a health care professional said that the meals are excellent and enjoyed by all the service users. Service users are given a copy of the menus in advance so they have an opportunity to choose something else if they do not like what is on the menu. They also have the opportunity to change their minds at short notice if they decide they would prefer something else when they see the meal being served. Service users said that breakfast is served in their rooms and discussions with several people confirmed that they may have whatever they like for breakfast, cooked or otherwise. Bowls of fruit are available on each table in the dining room and service users may help themselves. Service users who require assistance with eating their meals are served in the small lounge/dining room so that they have some privacy and dignity is preserved. Service users and the Cook confirmed that special diets are catered for, such as gluten free, diabetic, or vegetarian and, where required, nutritional plans are in place that follow advice given by doctors and dieticians. The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is excellent. Service users can be confident that any concerns or complaints are treated seriously and that they will be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure and appropriate information is posted on the notice board and contained in the Statement of Purpose and Service User Guide. Service users said that they know how, and to whom, to make a complaint should they need to. Service users said that they had confidence in the Registered Manager and the staff team to resolve any issues as soon as they arise. However, service users also said they have no complaints about the home or the care they receive. Discussion with the Registered Manager confirmed that she looks into all comments or complaints, no matter how small, and uses the information to constantly review services and make improvements if necessary. All staff have attended, or were expected to attend, training related to the protection of vulnerable adults and the Registered Manager is clear about the procedure to follow if necessary. This was demonstrated by a recent incident where a false allegation was made about a senior member of staff but the Registered Manager followed the reporting procedure and no further action was The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 15 taken by Social Services. There is a visitors book in the front hallway to record dates, times and names of all visitors to the home. The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 16 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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. The service users live in a pleasant, well-maintained home that is comfortable, warm and clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All private and communal rooms are attractively decorated, the furnishings are of a high quality and the home is well maintained. Service users and relatives confirmed that the home is comfortable and always warm and clean. There are some adaptations for service users with mobility difficulties such as ramps and a passenger lift that has access to all levels. Grab rails, raised toilet seats and rails, hoists and any other aids are provided in all areas where they are required. The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 17 The home has a large lounge and a dining room on the ground floor and there is another room, which is used both as a lounge room and a dining room. There is a call bell system installed throughout the home. Twenty-eight of the bedrooms are single and there is one double room on the 1st floor. Several bedrooms do not have locks fitted to the doors but the Registered Manager confirmed that locks are fitted if service users request this. Being able to lock bedroom doors helps to ensure privacy and means that belongings can be secured should the service user be away from the home for any reason therefore these should be fitted without service users having to make a specific request. All the bedrooms are well decorated, comfortably furnished and personalised with service users own pictures and ornaments. Lockable storage facilities are provided in every room. Seventeen bedrooms have en suite toilets and bathing, showering and toilet facilities are available on each floor, close to bedrooms and communal rooms. Service users said they are satisfied with the laundry arrangements and none of the service users spoken with had experienced any items going missing or being damaged. The garden is large, with flower beds, lawn, walkways and seating and provides a pleasant, safe environment for service users. The garden is easily accessible from the house and many rooms have a view of it. Service users commented on how much they enjoy looking at the garden, particularly the birds, squirrels and a peacock that has recently appeared. The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. Service users are cared for by motivated, knowledgeable, capable and caring staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment practices protect vulnerable service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation and discussion with service users and staff confirmed that the staff team are respectful, polite, attentive and responsive to service users’ needs. Service users described the staff as very kind and caring and confirmed they responded promptly to requests for assistance indicating that there are sufficient staff to meet the needs of those currently living in the home. As well as the care staff, the home employs administrative, catering, domestic and maintenance staff. There are usually a minimum of five care staff on duty in the mornings, three in the afternoon/evening and two waking night staff. The Registered Manager and staff confirmed that staffing is flexible depending on the needs of the service users and agency staff are used if required. Comments received from a health care professional confirmed that the home is “always well staffed by friendly, enthusiastic carers.” Staff turnover is extremely low and many staff members have worked at the home for several years, thereby providing consistency for the service users. The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 19 New staff members complete a comprehensive induction course that cross refers to National Vocational Qualifications (NVQs). Each staff member has a personal training and development programme and there is ongoing training for all staff members. This includes health and safety, first aid, medication, manual handling, fire safety, food hygiene, hazardous substances, infection control, dementia care, managing challenging behaviour, adult protection, wound care, communication, end of life care and National Vocational Qualifications (NVQs). Recruitment processes are robust in that two written references are obtained as well as a Criminal Records Bureau (CRB) check and the Registered Manager confirmed that new staff are supervised until satisfactory references and checks are obtained. The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 20 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, 32, 33, 35, 36 and 38 Quality in this outcome area is excellent. Service users live in a very well managed home and benefit from an open and inclusive ethos. The management and staff team strive to provide a stimulating, safe environment where service users are respected and rights are upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager, Kathy Daw, has many years experience of working in a care home and has been managing this home for approximately seven years. She is a Registered General Nurse and is in the process of completing the Registered Manager’s Award. She undertakes periodic training to update her skills, knowledge and competence for example, recently attending a seminar The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 21 about the new Mental Capacity Act that is due to come into force this year. In addition, she is also an Assessor for National Vocational Qualifications (NVQs), therefore can assist staff with their NVQ work. Service users and relatives were very complimentary about Mrs Daw’s management skills and her acceptance of service users’ different needs. Service users said that they feel safe and secure in their home and that the home is well managed. A service user described Mrs Daw as a “lovely, kind and thoughtful person”. A relative commented that she has the attitude that this is the service user’s home and service users are treated in the way that they want. Staff confirmed that they are well supported by the Registered Manager on a day-to-day basis, through regular staff meetings and supervision sessions. Comments from a health care professional confirmed respect for the manager and the way she manages the home. The service users or their families/representatives manage their financial affairs, although the home does manage small amounts of spending money on behalf of service users. The spending money of three service users was checked and found to be correct, with up to date records kept. Health and safety practices are satisfactory in that equipment is maintained in good working order and staff receive training in health and safety, fire safety, first aid, food hygiene, infection control, hazardous substances and manual handling. Inspection of the fire logbook indicated that regular tests/checks of the fire alarm system/equipment are carried out. The Cook keeps records of fridge/freezer and cooked meat temperatures and there was a cleaning rota available in the kitchen. The Registered Manager confirmed that window restrictors are fitted to all windows above the ground floor, the radiators are guarded and all hot water outlets accessible by the service users are regulated, to reduce the risk of burns and scalds. The home records all accidents and the Registered Manager monitors this to identify the reasons, check for risk areas and look for any patterns. If required, reviews of a service user’s care will be arranged and health and social care professionals consulted. A quality assurance system is in place and service users’ views are sought through meetings or individually. This quality assurance system should be developed to include an annual internal audit of all the services and facilities in the home to confirm that everything is in good working order, documentation is up to date and the home is run in the best interests of service users. The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 22 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 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 4 17 X 18 3 3 4 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 3 X 3 The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP9 OP24 Good Practice Recommendations The refrigerator used to store medicines should only be accessible by staff members to ensure the safety of service users and the security of the medication. Locks should be fitted to all bedroom doors that are suited to service users’ capabilities and accessible to staff in emergencies. This is so that service users can have privacy if they wish to and belongings can be kept secure should service users be away from the home for any reason. The quality assurance system should be developed to include an annual internal audit of all the services and facilities in the home to confirm that everything is in good working order, documentation is up to date and the home is run in the best interests of service users. 3. OP33 The Manor House DS0000060572.V327767.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 DS0000060572.V327767.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!