Inspection on 15/05/08 for The Manor House

This inspection was carried out on 15th May 2008.

CSCI found this care home to be providing an Adequate service.

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 16/05/07

The Manor House 18/05/06

The Manor House 07/02/06

The Manor House 12/07/05

The Manor House 13/01/05

The Manor House 18/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Manor House Hall Lane Old Farnley Leeds West Yorkshire LS12 5HA Lead Inspector Sean Cassidy Key Unannounced Inspection 15th May 2008 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 DS0000001479.V364311.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 DS0000001479.V364311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Address Hall Lane Old Farnley Leeds West Yorkshire LS12 5HA 0113 2310216 P/F 0113 2310216 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) Mr Chamkaur Singh Dhaliwal Mrs Manmohan Kaur Dhaliwal Mrs Irene Foster Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2007 Brief Description of the Service: The Manor House is a converted stone building that has been extended to provide residential care, without nursing, for thirty older people. The home is located west of Leeds, adjacent to the local park, with a housing estate and bus routes nearby. There are 22 single and 4-shared rooms over two floors. A shaft lift gives access to the second floor. There are four communal lounges, separate dining space, three bathrooms and one shower room. Toilets are near to the lounge areas and bedrooms. The gardens are well maintained with outdoor seating areas. Prospective residents are provided with ample literature prior to admission to inform them of the services and facilities provided at The Manor House. Fees charged are at the current basic Local Authority rates, for both privately funded and publicly funded people. The fees charged at the time of the inspection were £432 per week. The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence in this report has included: • • • A review of the information held on the home’s file since the last inspection. Information obtained from residents, relatives, staff and other health care professionals. Information supplied by the manager within the Annual Quality Assurance Assessment One inspector conducted an unannounced visit to the home, which lasted one day. The majority of this time was spent examining documentation, speaking to residents, management, staff and relatives. A number of documents were looked at during the visit and some areas of the home used by the people living there were visited. A proportion of time was spent speaking to the manager, the registered providers, staff and visitors. Feedback was provided at the end of the inspection to the manager and provider. I would like to thank everyone who contributed to this report, and for the hospitality on the day. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes What the service does well: The home works in partnership with health care professionals to ensure that peoples’ health care needs are met. Staff were observed to work well with the resident group promoting respect and dignity when possible. The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 6 Meal times are promoted as a social occasion and people said they enjoyed the food provided in the home. The manager has developed a monthly newsletter that is produced in large print. People living in the home benefit from a low staff turnover. This helps to provide them with a continuity of care. What has improved since the last inspection? What they could do better: The Statement of Purpose must include up to date information on the care needs of people that are provided in the home. This will ensure people moving into the home will have made a fully informed choice to do so. It is recommended that the manager assess prospective service users prior to visiting the home and also during a visit whenever possible. This will help the manager to ensure appropriate admissions are made. Care plans must include all the necessary detail needed to ensure the care needs of each individual can be met. They must also provide evidence that the person or their representative have been involved in the process. A person centred care approach should be adopted in the care planning documentation. This will help provide carers with a more in depth picture of each individual and there fore assist them with providing for all their identified needs. The care documentation should be locked away so that the personal information contained within them is properly protected. The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 7 Risk assessments should be developed for all areas where a risk to staff and residents has been identified. This will help minimise the risk of harm occurring. The activities provided both inside and outside the home must reflect the wishes of the people living there. Particular attention must be paid to the specialist needs of people with dementia. The manager should review the complaint procedure to ensure the contact details for the Commission for Social Care Inspection are correct. The safeguarding policy must be robust and contain all the necessary information to ensure staff are fully informed with regards to the home’s policy and procedures in this area. The staff employed to provide care in the home must not be involved in the day-to-day domestic duties identified in the home. This will ensure people living in the home are suitably supervised at all times and there are carers available to meet their needs. All the required information needed before an employee must be obtained prior to commencing work in the home. This will help ensure people are appropriately protected. The staff must be provided with a structured training programme that focuses on the care needs of the people living there. This will help to provide staff with a better understanding of the care needs of the people they are working with. There must be a system in place for evaluating the quality of services provided at the care home. An Improvement plan must also be developed which provides clear methods and timetables as to how improvements will be made. This will provide residents and their relatives with assurances that the provision of quality care is high on the care homes’ agenda. The home must include a photograph in the records of all people who live at the home. This will help staff to accurately identify anyone they are about to carry out a procedure with, particularly the giving of medication. (Previous timescale of 31/8/07 was not met) 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 DS0000001479.V364311.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 DS0000001479.V364311.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): 1 and 3. Quality in this outcome area is good. People said they felt they were provided with enough information to make a choice whether to take a place or not. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose / Service User Guide. The manager said people are provided with this information at the point of admission to the home. This was confirmed by speaking to two relatives who said they were given enough information to make their decision before their relative was admitted. The Statement of Purpose does not provide the reader with a clear picture of the care needs of the people living there. Although the home is not registered for people with dementia, it was clear during the inspection there were a number of people with different cognitive needs living in the home. This The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 10 document should be reviewed so that it provides prospective residents and their relatives with up to date information that will help them make an informed choice about moving into the home. The manager also said that people are given the opportunity to come and look around before they moved in. This was also confirmed through feedback from relatives. One relative spoken to said “ We were given good information about the home and were invited to have a look around. We got a good feel about the place when we visited.” The manager said she does not go out to the place where a prospective resident is residing before admission. They are assessed in the home when they come to visit and sometimes, if things are ok at the time, they stay after the assessment. It was recommended to the manager that an assessment of all prospective individuals should take place prior to entering the home and if possible, at a visit to the home as well. This will enable the manager to ensure the home will be able to meet that individual’s care needs. It will also ensure that the risk of having to move a person to another care home is reduced. The Manor House DS0000001479.V364311.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): 7,8,9 and 10. Quality in this outcome area is adequate. The care documentation does not contain the person centred detail needed to ensure the care needs of people are met. People receive their care in a manner that respects their privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of three people were case tracked as part of the inspection. Each person had a plan of care in place and the records showed the home involved the care of other health care professionals such as GPs and district nurses when the need arose. A district nurse was visiting the home during the The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 12 inspection. The district nurse said the home worked closely with her team and involved them when they needed to be. The previous inspection identified the home had introduced a new care planning system. All people living in the home are now included in this system. Discussions were held with the manager about the content of the information included in these documents. The detail included in the care plans inspected lacked any person centred detail to enable staff to provide the care needs that were identified in the assessment document. One person had been assessed as being blind, deaf and having an aggressive nature. These areas had not been addressed in the care plans or risk assessments. One individual’s daily records had identified that she was particularly aggressive on several occasions. There was no risk assessment or care plan to deal with this issue or any evidence to show the home had involved the assistance of another health professional. This places other people and staff at risk of possible harm. The three care files inspected showed no evidence that the resident or their representative was involved with the process. The manager and deputy manager consented to some documents. Three visitors said they had not been involved with the development of the documentation and said they would like to be. This is not good practice and is evidence to show the home does not promote the choice and involvement of the individual. Not all care plans and risk assessments have been reviewed monthly. In some cases there were gaps of three months where they had not been reviewed. Care plans now contain photographs of the person who the care is planned for. However, the manager has not obtained consent from residents or their representatives for this action. The use of photographs assists residents to have a sense of identity and ownership of the documentation used to plan the care. Staff were observed providing care to people living in the home. This was carried out in a manner that was respectful and dignified. There was good communication between the staff group and the people who live there. Staff spoken to said they enjoyed working at the home and many of them have been there for quite a long time. People spoken to spoke highly about the staff team and the relationship they had with the residents. They said that the staff were very good at providing information about health care changes with their relatives. Some comments made by people who live in the home were, “ The staff are all very kind and helpful.” “ The staff are great at having a laugh with the residents” The medication administration charts were randomly inspected and all appeared to be completed well. The lunchtime medications were observed being administered following correct guidelines. It was noted that all the medication pots in the trolley had individual names on them. This suggests The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 13 that the practice of secondary dispensing may be taking place. This was passed to the manager to speak to the staff group about, as it is poor practice. There was no evidence seen to show people are risk assessed at admission to monitor whether they are able to self medicate themselves. This restricts peoples choice if they are not involved in this process. The medication trolley was not securely fastened to the wall where it was stored. The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 14 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): 12,13,14 and 15 Quality in this outcome area is adequate. There is an inconsistent approach to ensuring people are provided with an activity programme that meets their assessed needs. This means that people are not enjoying a quality of life that is fulfilling and meaningful. Staff carry out their duties in a manner that is both respectful and dignified. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has developed a quarterly newsletter that includes information that informs people about past and future events. This is written in large print for those that have visual difficulties. Three residents and three relatives spoken to were unaware of the newsletter and had to be guided to it on the notice board. There was a notice board at the entrance of the home that provided people with up to date information about the home and activities that are planned. The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 15 This board was very cluttered and it was difficult to identify what exactly was pinned to it. Two relatives suggested it might be a good idea to have it in a more suitable area where it could be more accessible. One relative said, “ You feel as if you are in the way when you stop to try and read the notice board in the hall.” Information around the home was displayed in restricting places and inaccessible to residents. For example, the menu displayed on the wall was about three metres off the ground, which made it very difficult to read. This should be reviewed so that all information on display be accessible and in a format that can be understood by the people it is aimed at. On the day of the inspection a lady was providing residents with an exercise class in the living room. She said that she comes every two weeks to provide this class. There were thirteen people in the living room during this class and seven were actively involved and appeared to enjoy themselves. The activities provided both inside and outside of the home were displayed on the notice board and around the sitting room. A barbecue and cake making activity were planned. People spoken to said that the provision of activities both inside and outside the home was an area that needs attention. Some comments made by people in relation to activities were, “There is nothing much going on with regards to activities which surprises us.” “I think there is something missing with activities.” “ She was a very active woman and was a great gardener. There doesn’t seem to be much encouragement to do anything here.” The manager confirmed that there are no activities planned for outside the home. People said they would really like to see more planned activity. The gardens are not openly used because of the health and safety risks that are present. These risks could easily be removed with some planning and this would enable easy access to the gardens for all. It was recommended that residents could be involved with gardening activities and garden maintenance. This could help provide a sense of well- being. The entrance to the garden is a fire exit that was locked by a key. This is poor practice as it is blocking a fire exit and is also restricting access. The records that were inspected provided very little evidence to show how people spent their days. There were no activity care plans seen in the files that were inspected. This made it very difficult to get a picture of what people were doing every day. There are no meetings held with the relatives or their relatives in the home, which meant there was little evidence to show how decisions were made about what activities should be provided. The manager said that they tried meetings in the past but they didn’t work. The people spoken to during the inspection gave a positive reaction to the chance for relative/resident meetings. The manager should look to developing this area. The lunchtime meal was observed and was seen to be a very social occasion. People were sat together in the dining room. The dining tables were well The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 16 presented and attractive. There was plenty of conversation and interaction with the people on duty. Menus were displayed on the tables and they provided people with a good choice. There were positive comments made by all about the standard of the food. Fresh fruit was also on display for people who wanted it. The cook provided evidence that she had a good awareness of people’s likes and dislikes and how these were provided for. The Manor House DS0000001479.V364311.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): 16 and 18 Quality in this outcome area is good. People are enabled to make complaints about the service they receive. The safeguarding processes adopted by the home help top ensure they are appropriately protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does have a complaints procedure and this is well displayed throughout. It informs the reader how to make their complaint known and how it will be investigated. The manager said that they have not had any complaints since the last inspection. People spoken to say they felt comfortable approaching the manager with any complaint they might have and they said they were confident that the complaint would be properly investigated. It was pointed out to the manager that the complaints policy was in need of review as the contact details for the Commission for Social Care Inspection were out of date. Staff members spoken to about safeguarding adults had a good awareness of this area. They knew what signs they would look for that would indicate abuse might be taking place. They also knew that they would go straight to the manager or person in charge if they suspected someone was at risk. However, the policies and procedures for Safeguarding adults were not robust and did The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 18 not incorporate the local authority guidelines in this area. There was no procedure available to guide staff in the event of a safeguarding issue that needed referring to the safeguarding team or the police. Two visitors spoken to both said they felt their relatives were safe and well cared for at the home. The Manor House DS0000001479.V364311.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): 19 and 26 Quality in this outcome area is good. People live in an environment that is suited to their needs and expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People spoken to said they were happy with the standard of the environment of the home and that it suited their needs. Some comments made were, “ There is a real homely feel about the home.” “Mum says she likes the home as it gives her a comfortable feeling.” “ They’ve made some nice changes recently. The hairdressing salon is a bonus.” The home has attractive gardens, which are used by some people but not consistently. There were some areas that need to be made safe so that people can wander around the grounds in the nice weather without being placed at The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 20 risk of injury. This action would improve the environment of the home but also the well being of people living there. The manager highlighted the recent improvements that have been made in the home. These included a new hairdressing salon, a refurbished toilet, a refurbished bathroom that includes a walk-in shower and also some extra storage space. The improvements have been completed to a good standard. The bedrooms seen showed good evidence that people are encouraged to personalise their rooms whenever possible. This promotes choice and individuality The home employs a contract domestic and has recently employed a domestic from a local employment agency. The manager said that staff working in the home also get involved in the cleaning duties. This should be reviewed and actions taken to ensure suitable numbers of care staff are employed. This will enable staff to concentrate on the priority of care provision. Feedback from people spoken to was positive about the standard of cleanliness in the home. However, there was a malodour noted in one person’s room. This was particularly strong and has been a long-term problem, which was highlighted at the previous inspection and should have been addressed. The manager was asked to review the situation and put plans in place to deal with the issue. The Manor House DS0000001479.V364311.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): 27,28,29 and 30. Quality in this outcome area is adequate. People living in the home are not appropriately protected by recruitment procedures adopted by the home. People feel the staffing numbers are sufficient to meet their needs. However, when care staff are performing domestic duties they are being removed from their role as carer. This can place people at possible risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has developed and maintained a rolling staff rota that helps to ensure the appropriate number of people are on duty at all times. People spoken to during the inspection said the staff worked well with the people who lived there and that they seemed confident when providing care packages to people. Three residents spoken to said there seemed to be enough people on duty. They said, “ There seems to be enough of them on duty. They are always quick to help me when I need it.” “You sometimes have to wait a little while for The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 22 the buzzer to answered, but they are usually quick to help.” “ There seems to be enough people on duty when we visit. They seem to have time to sit and chat to people.” The recruitment files for the two most recent care staff employed at the home were requested. The provider could only produce the employment records for one of these people. I asked to be contacted with the second persons records but this did not happen. The recruitment file seen showed the correct information was obtained prior to commencing employment. A discussion was held about the appropriateness of staff working in the home providing references for prospective employees. Good practice recommends alternative references should be obtained. Staff are provided with up to date training in mandatory areas. Staff also confirmed they have received training in areas such as dementia, palliative care and medication. It was recommended that the manager develop a training matrix to assist with the planning of relevant training. It was noted that 75 of the care staff have been trained to NVQ level 2 standard. Each new member of staff is provided with a structured induction. This must also be provided to all agency staff on long-term contracts. The domestic working at the home has not received an induction, fire training, infection control training, COSHH training (Control of Substances Harmful to Health) or safeguarding training. The absence of this training places both her and others at risk. The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 23 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): 31,33,35 and 38. Quality in this outcome area is adequate There is a lack of quality assurance in the home. This means people do not benefit from a service that is regularly reviewed and improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has 10 years experience running the home and has a recognised management qualification. She is a very hands on manager and enjoys working closely with the resident group. People spoken to said they felt the manager was approachable and said they would be happy to approach her about any concerns they might have. The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 24 The registered provider visits the home on a monthly basis to carry out a Regulation 26 visit. The reports completed for the last three months were seen and they contained evidence to show people who work in and use the service were spoken to. The manager uses questionnaires to help gain views of the residents and their relatives. This information is not correlated and presented to the stakeholders of the home. This would give people an opportunity to show that their views are listened to and action is taken to improve the care provided in the home. The manager does not use a recognised quality assurance system to allow her to review and improve the quality of care provided in the home. There was no evidence to show regular audits of all care systems are taken to ensure quality is maintained. Refurbishment work has been carried out and more is planned, however there is no annual refurbishment programme in place that allocates a realistic budget for planned work. This is also the case for the training programme for the home. A recognised system for assuring quality care would improve the standard of care service provided to people who live in the home. The manager said they look after the pocket monies of some residents and these are securely stored and managed. The records of this system were not reviewed at the site visit. The Annual Quality Review provided information to show the home ensures all the equipment is check and maintained on a regular basis. The manager also provided information to support this. The emergency lighting was being replaced at the time of the inspection. The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 25 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 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x x x 3 The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4 Sched 1 Requirement Timescale for action 31/08/08 2 OP7 15(1) 3 OP12 16(2)(m) 4 OP27 18(1)(a) The Statement of Purpose must include up to date information on the care needs of people that are provided in the home. This will ensure people moving into the home will have made a fully informed choice to do so. Care plans must include all the 31/08/08 necessary detail needed to ensure the care needs of each individual can be met. They must also provide evidence that the person or their representative have been involved in the process. The activities provided both 31/08/08 inside and outside the home must reflect the wishes of the people living there. Particular attention must be paid to the specialist needs of people with dementia. The staff employed to provide 31/07/08 care in the home must not be involved in the day-to-day domestic duties identified in the home. This will ensure people living in the home are suitably supervised at all times and there DS0000001479.V364311.R01.S.doc Version 5.2 The Manor House Page 27 5 OP29 19(1)(a) Schedule 4(6) 6 OP30 18(1)(a) 7 OP33 24 are carers available to meet their needs. All the required information 31/07/08 needed before an employee must be obtained prior to commencing work in the home. This will help ensure people are appropriately protected. The staff must be provided with 30/09/08 a structured training programme that focuses on the care needs of the people living there. This will help to provide staff with a better understanding of the care needs of the people they are working with. There must be a system in place 30/09/08 for evaluating the quality of services provided at the care home. An Improvement plan must also be developed which provides clear methods and timetables as to how improvements will be made. This will provide residents and their relatives with assurances that the provision of quality care is high on the care homes’ agenda. 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 OP3 Good Practice Recommendations It is recommended that the manager assess prospective service users prior to visiting the home and also during a visit whenever possible. This will help the manager to ensure appropriate admissions are made. A person centred care approach should be adopted in the care planning documentation. This will help provide carers with a more in depth picture of each individual and there fore assist them with providing for all their identified DS0000001479.V364311.R01.S.doc Version 5.2 Page 28 2 OP7 The Manor House 3 4 5 6 OP7 OP7 OP16 OP17 needs. The care documentation should be locked away so that the personal information contained within them is properly protected. Risk assessments should be developed for all areas where a risk to staff and residents has been identified. This will help minimise the risk of harm occurring. The manager should review the complaint procedure to ensure the contact details for the Commission for Social Care Inspection are correct. The safeguarding policy should be more robust and contain all the necessary information to ensure staff are fully informed with regards to the home’s policy and procedures in this area. The Manor House DS0000001479.V364311.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 DS0000001479.V364311.R01.S.doc Version 5.2 Page 30 - 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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