Inspection on 16/05/07 for The Manor House

This inspection was carried out on 16th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Manor House 15/05/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Manor House Hall Lane Old Farnley Leeds West Yorkshire LS12 5HA Lead Inspector Stevie Allerton Key Unannounced Inspection 16th May 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Manor House DS0000001479.V338384.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.V338384.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 N/A 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.V338384.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. This inspection was carried out by one inspector, carrying out a site visit over the course of one day, then analysing further information when it was supplied three weeks later. The visit was not announced beforehand. The Manager was on duty and assisted the inspector throughout the day, as did other key staff. A random inspection had been carried out on 14th February 2007, to follow up on issues that had been raised at the previous key inspection and to investigate a complaint that had been made. Some recommendations had been made as a result, which were followed up during this visit. Prior to the visit, accumulated information about the home was reviewed, including notified events such as deaths and accidents. The Manager did not supply statistical and other written information until three weeks after the visit, therefore people who live at the home, their relatives and other health and social care professionals involved with them could not be identified and surveyed beforehand. Some survey forms were left at the home on the day of the visit, for people to complete if they wished. None had been received by CSCI at the time of writing this report. The comments made by people that are included in this report are confined to those who were able to speak to the inspector on the day. What the service does well: The home has a good track record of being able to provide appropriate support for people who have not “fit in” to other services. The home works in partnership with health care professionals, to ensure that peoples’ health care needs are met. The systems in place for managing The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 6 medication are safe, without removing the right of individuals to look after their own. The routines of the home are flexible and carried out around individuals’ needs and wishes. One comment was, “I can go to my room whenever I please. I don’t have to join in if I don’t want to.” People enjoy the food and look forward to mealtimes. “It’s good home-cooking, the meals are lovely”. The home is willing to act on suggestions and requests made by the people who live there, to improve the service they provide. There is a monthly newsletter, produced in large print. People spoken to all said that they had confidence in bringing any problem to the attention of the Manager, who sees people on a daily basis and is felt to be accessible. They felt satisfied that she would act upon any complaints. The low staff turnover means that people are being looked after by a stable team of workers that they, and their families, can forge relationships with. Staff were observed dealing with the people who live at the home in a friendly and confident way and people said that they felt safe and well cared for by the staff. “The staff are a great bunch of lasses, they’ll go to the shops for me to get the things I want.” What has improved since the last inspection? Staff have had training in medication and some alterations have been made to care plans resulting from this. There is now a care plan for looking after someone’s medication, the Manager saying “we can’t presume they don’t want to do this for themselves”. There was a good example of how risk had been identified for individuals, and care plans drawn up that gave consent to staff to administer medication on their behalf. There are a high number of people who smoke and work was in progress to create a specific smoking room in preparation for the new law coming into force on 1st July. This will improve the environment in the lounge that was formerly used, for those who do not smoke. People spoken to all said that they had confidence in bringing any problem to the attention of the Manager, who sees people on a daily basis and is felt to be accessible. People say they feel satisfied that things brought to the attention of the Manager will be acted upon. The success of NVQ (National Vocational Qualifications) training and the willingness of the staff team to undertake the additional training needed to meet the standards, shows that staff are keen to improve the quality of the care they can give to people. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 7 Quality surveys are carried out twice a year and there is evidence that action has been taken to improve facilities in response to suggestions made. The Manager has also taken action to improve practice, by acting upon most of the requirements and recommendations made during CSCI inspections. 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 DS0000001479.V338384.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.V338384.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): 3 (Standard 6 is not applicable in this service) People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who come to live at the home have a reasonable expectation that it will be able to meet their needs, through the introductory visits and the standard written information that is given to them on admission. The home has a good track record of being able to provide appropriate support for people who have not “fit in” to other services. EVIDENCE: On the day of inspection, a gentleman came to look round with a view to moving in, from another registered service out of the area; his family had already been to see the home. He told the staff that he had decided that he would like to stay and would be happy to move in the following week. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 10 The Manager and Deputy said that they always try wherever possible to assess prospective residents during a visit to the home, rather than in hospital, feeling that the person needs to see the home before making a decision. The person would get a copy of the Service User Guide when they come to stay. They would be reviewed in 6 weeks and the contract signed at that point. The person or their family keeps their own copy of the contract. 22 beds are on block contract with Leeds City Council. The care files looked at contained appropriate assessment information, which showed that the home was only admitting people that they have a reasonable expectation of being able to provide care for. There is a high proportion of men living at the home (almost 50 at the site visit). The Manor House DS0000001479.V338384.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 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans set out clearly for the staff what action has been agreed with each person and/or their family, that needs to be done to meet their physical, emotional and social needs. The home works in partnership with health care professionals, to ensure that peoples’ health care needs are met. The systems in place for managing medication are safe, without removing the right of individuals to look after their own. EVIDENCE: Care plans were looked at for four people with a range of care needs. There are still some people with the older version of the care plans. This has been identified as a target for the next 12 months, transferring all information onto the new format. Some care plans did not have a photograph of the person. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 12 There was evidence in the records to show that the home works in conjunction with GPs, District Nurses, Community Psychiatric Nurses (CPNs) and other health professionals to meet the physical and mental health needs of the people they care for. Risk assessments are carried out for Moving and Handling, Nutrition and risk of Falls. One person whose nutritional risk assessment showed them to have a low BMI, had been referred to the GP, who had no concerns about their weight at this time. There was evidence that diabetes is closely managed with the District Nursing team. One person has a supra-pubic catheter in situ, which they manage themselves, supported by the District Nurse. The home has close contacts with the community-based cross-infection team; the Manager said that they visit regularly to ensure that staff have the correct equipment in place and give advise on hand-washing, etc. Aids and adaptations are obtained where people have a need, eg, pressure-relieving mattresses and cushions, or adapted cutlery where manual dexterity is a problem. Records showed that changes in health are picked up by the staff and referred appropriately to the GP. One person has a CPN who visits regularly and who writes her own notes in the designated place in the care plan. Some people have been able to sign their own care plan documents. There was evidence that the staff work alongside relatives to try to achieve a better outcome for people, particularly with regard to managing behaviour. Daily records reflected the plans of care and there was evidence that they are reviewed and updated regularly. There are a high proportion of men living at the home, but no male staff members. Those who were asked about this said that this did not bother them. One man said that he had been at the home for 2 years. He likes the staff and finds them very helpful. “I’ve got everything I need here”. Another man who was approached thanked the inspector for being interested in his welfare, but said that he hadn’t time to talk as he was watching a film on TV. Staff have had training in medication and some alterations have been made to care plans resulting from this. There is now a care plan for looking after someone’s medication, the Manager saying “we can’t presume they don’t want to do this for themselves”. There was a good example of how risk had been identified for individuals, and care plans drawn up that gave consent to staff to administer medication on their behalf. A senior carer was observed at lunchtime dispensing medication in the dining room; good practice was observed and records reflected the practice. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social, cultural and recreational activities meet peoples’ expectations. The routines of the home are flexible and carried out around individuals’ needs and wishes. People enjoy the food and look forward to mealtimes. The home is willing to act on suggestions and requests made by the people who live there, to improve the service they provide. EVIDENCE: The findings of the previous random inspection were confirmed at this visit. Seven people were spoken to in the dining room and another three in their own bedrooms. FOOD: Lunch was taken in the dining room with the people who live at the home. There was a choice of 3 main courses and staff were observed offering The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 14 choices to people. The menu shows a good variation of meals, including some foreign dishes, as a result of people making suggestions. The care plan for one of the people who was case tracked showed that meals were sometimes taken in her own room, clearly not a problem for staff to accommodate this request. One person was confused and restless and kept leaving the table, so staff took the food to her and very patiently succeeded in helping her to eat the full meal. There was a good atmosphere in the dining room and residents were helping each other, as well as the inspector, passing the condiments or filling glasses from the jug on each table. They said they liked the food and found the staff helpful and accommodating. Activities and daily life: There is a monthly newsletter, produced in large print, and families are encouraged to be involved in day to day matters. Many people have highly personalised bedrooms, with pictures and ornaments brought from home. Quality surveys have been carried out, and action taken to improve areas of the home in response to suggestions, eg, the change of visiting hairdresser. There are a high number of people who smoke and work was in progress to create a specific smoking room in preparation for the new law coming into force on 1st July. There is a range of planned activities and entertainment and staff have access to a good resource file for setting quizzes. One of the people case tracked is deaf and uses earphones to watch TV in her own room. People spoken to said they were satisfied with daily life at the home. “It’s not the same as being at home, but the staff try hard.” “I can go to my room whenever I please. I don’t have to join in if I don’t want to.” Visitors were in the home during the site visit and were given the opportunity to speak to the inspector, but declined. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home are supported to exercise their rights to make choices and decisions. The complaints procedure is generally understood and accessible to most people. People say they feel satisfied that things brought to the attention of the Manager will be acted upon. The recent training on safeguarding vulnerable adults will need to be updated and refreshed at regular intervals, in order that people living at the home know that their protection and safety is a priority. EVIDENCE: The complaints system is displayed, along with forms and envelopes, to allow privacy if so wished. People spoken to all said that they had confidence in bringing any problem to the attention of the Manager, who sees people on a daily basis and is felt to be accessible. The outcome of the last inspection, during which a complaint was investigated, is freely available to everyone to read. Staff have received training in the protection of vulnerable adults, which the registered provider also attended. The written procedure for reporting suspicions of abuse is readily available for staff to use. The staff team The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 16 understand about maintaining individuals’ rights and freedom of choice, as evidenced by the content of the care plans. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely environment, which is safely maintained. Some of the rooms are shared, so those people do not have as much privacy and autonomy about how they use their rooms as those who have their own keys. Staff are trained in hygiene, safe moving and handling and fire precautions, which ensures the safety of the people living there. There has been some renewal and redecoration over the past 12 months, which has improved the environment. The location of the kitchen, and the laundry layout, create difficulties in maintaining the best hygiene practices, but there are measures in place to minimise these risks. The addition of a designated, well-ventilated area for smoking, and a walk-in shower, will provide greater comfort for the people living at the home. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 18 EVIDENCE: A tour of the building was carried out. Certificates were also seen, providing evidence that routine maintenance and safety checks, eg, electrical wiring, gas and water storage, are carried out by the appropriate bodies. Signs were in place to discourage staff and visitors from using the kitchen as a thoroughfare and the Manager said that this was generally improving. Recommendations were made at the most recent Environmental Health Officer’s inspection of the kitchen, and the Hazard Analysis documentation has now been introduced. General fire safety appeared to be good. All WCs & bathrooms were equipped with the correct items to maintain good hygiene. Work was underway to create a smoking room, with appropriate ventilation, in what was the staff room & WC. The staff WC is to re-locate in the annexe. Plans are to create a new shower room upstairs once the current building work has been completed. Appropriate aids to mobility are available and in use, including bath hoist and a mobile hoist. Two staff members were observed moving a lady with the mobile hoist, maintaining good safe practice and explaining to the lady what was happening. This person also has foam wedges placed either side of her when in bed, to prevent her rolling out, felt to be more appropriate and safer for this individual than bed rails. Some people living at the home have their bedroom door key and actively use it, choosing to lock their room door overnight. This was noted in their care plan and there is a system in place whereby staff can gain entrance to the room if there is a problem. Approximately 8 bedrooms were seen, most of which were highly personalised and reflected the tastes and interests of the occupant. One bedroom that was seen had an odour, which the Manager was aware of, the staff currently working with the person and their family to try to manage the problem effectively. Outside, there are large attractive gardens and a patio area where people can sit in fine weather. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures follow the regulations and ensure that only properly checked and vetted staff work with the people who live at the home. Induction training for new staff is in place, but needs to improve, and to cover Moving and Handling and Adult Protection as part of the early initial training, so that people who live at the home are kept safe at all times. The success of NVQ training and the willingness of the staff team to undertake the additional training needed to meet the standards, shows that staff are keen to improve the quality of the care they can give to people. The low staff turnover means that people are being looked after by a stable team of workers that they, and their families, can forge relationships with. EVIDENCE: Staff rotas reflected the numbers of staff that were on duty on the day of the inspection visit. The layout of the home has approx one third of the people who live there housed in the annexe, with bedrooms on two floors and a dedicated lounge. There are normally two staff on waking night duty, but if The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 20 they are caring for someone who is very ill or dying, then a third person is brought in. There are designated senior care staff as well as a Deputy Manager, with one of these always on shift. First Aid training has been given and there has also recently been some fire training. Staff are currently undertaking distance learning programmes: Safe Handling of Medicines, Cross Infection & Dementia are being completed with all staff on a rolling programme; 7 have completed the medicines course and 9 have completed the cross infection. One of the senior staff, who was observed giving medication, said that she had got a lot out of the recent training. The personnel file for the newest staff member was looked at. This showed that they commenced employment in February 2007 and that the required recruitment procedures had been adhered to, including background checks, Criminal Records Bureau checks, etc. Full induction training records were not seen for this staff member, as she holds her own record book and brings it in to be updated once a week. However, there was a record that the District Nurse had instructed her in use of the hoist, although no general Moving & Handling training had yet been given. The new Skills for Care Common Induction Standards were discussed with the Manager, and how to access them, so that the induction process currently in use can be updated. NVQ continues, with 9 care staff having completed Level 2 in Direct Care, plus the cook has NVQ Level 2 in Customer Care. 3 care staff are currently progressing towards Level 2. Staff communicate between shifts by way of a handover meeting; there is also a staff noticeboard and the Manager sees staff on a daily basis. Staff were observed dealing with the people who live at the home in a friendly and confident way and people said that they felt safe and well cared for by the staff. There was praise for the attitude of the care staff, and also for the cook, who was said to produce lovely, home-cooked food. There is a very low turnover of staff, with just one person having left employment in the last 12 months. The majority of care staff are in the 25 – 45 yrs age group and all are female. Three are from a minority ethnic group. The Manager discussed how support was being given to these staff, in the face of racial discrimination by one of the people who lives at the home. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Manager runs the home in the best interests of the people who live there, although issues of equality & diversity are not being considered, other than in recruitment of staff. Records are generally kept to a good standard, showing that the minimum requirements are met. The annual information now required by CSCI (the “AQAA”) provides opportunity for services to complete a self-audit and identify how they could improve and what action they intend to take to achieve those improvements. Very few areas were identified, the service relying on the CSCI inspection to lead improvement; a more proactive approach to the continuous development of the home would benefit the people who live there. Policies and procedures for maintaining health and safety in the home are in place, but the lack of moving and handling training to the newest staff The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 22 member, who had been at the home for 3 months, could place them and the people they are caring for at risk. EVIDENCE: Staff, relatives and the people who live at the home are involved in the decision making about how the home runs. Staff have the opportunity to discuss issues during individual supervision, which is now being recorded when it takes place. General and specific care issues are discussed informally on a daily basis. Quality surveys are carried out twice a year and there is evidence that action has been taken to improve facilities in response to suggestions made. Records seen at this visit included: care plans & daily records, medication records, menus, staff rotas, staff personnel files, training records, health & safety records, including fire safety and maintenance records. Written policies & procedures were also seen. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 23 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 3 2 2 The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 24 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. 1 Standard OP30 Regulation 18(1) Requirement Timescale for action 30/11/07 2 OP37 17(1)(a) Induction training for new staff needs to improve, and to cover Moving & Handling and Adult Protection as part of the early initial training, so that people who live at the home are kept safe at all times. The home must include a 31/08/07 photograph of all of the people who live at the home, within their records. This is so that staff can accurately identify anyone they are about to carry out a procedure with, particularly the giving of medication. 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 OP21 Good Practice Recommendations The proposal to alter existing bathroom/WC arrangements on the first floor, to provide a walk-in shower facility, would improve choices for residents. DS0000001479.V338384.R01.S.doc Version 5.2 Page 25 The Manor House 2 OP33 The annual information now required by CSCI (the “AQAA”) provides opportunity for services to complete a self-audit and identify how they could improve and what action they intend to take to achieve those improvements. Very few areas were identified, the service relying on the CSCI inspection to lead improvement; a more proactive approach to the continuous development of the home would benefit the people who live there. The Manor House DS0000001479.V338384.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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.V338384.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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