Inspection on 18/05/06 for The Manor House

This inspection was carried out on 18th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Manor House 15/05/08

The Manor House 16/05/07

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 Karen Westhead Key Unannounced Inspection 18th May 2006 09:00 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.V293878.R01.S.doc Version 5.1 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.V293878.R01.S.doc Version 5.1 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.V293878.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 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. Information about the fees and any additional charges was not available at the time of writing this report. The pre-inspection questionnaire had not been returned to the office in time to allow the information requested to be used. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) will be inspecting homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between April 2006 and June 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area and are known as random inspections. This was the first inspection of this home during for the 2006 to 2007 period. The visit was unannounced. Two inspectors were present and the visit started at 9.00am and finished at approximately 2.30pm. Feedback was given at the close of the visit. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. The last inspection of this service was on 7th February 2006. At that time thirty-three requirements and six recommendations were highlighted. The report was drafted and sent to the service provider. A written response confirms that the majority of these have now been addressed. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. Inspectors also spent a good proportion of their time talking to residents, staff and visitors. Residents who were unable to comment on their experiences were observed. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. One comment card asks questions about the inspection process and the way the inspectors carried out their duties. After completion these are returned to the CSCI. What the service does well: The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 6 The Manor House provides sufficient information to prospective residents, prior to admission. Admissions are well organised. Visitors are able to visit their relatives in private. Staff approach and treat residents with respect and their dignity is upheld. Health care needs are met. Food provision is satisfactory. Residents have choice and home cooking is regularly provided. The home provides a good range of activities, which are tailored to meet the differing needs of residents. Residents and their relatives have their views listened to, taken seriously and acted upon. Staff on duty have a good working knowledge of the resident group. Staff work as a team. What has improved since the last inspection? What they could do better: A significant amount of work has been invested in improving care plans. Some information was not being recorded. Medication records were not being completed appropriately. Wardrobes must be fitted securely and work is still required to up grade the laundry area. Not all the staff had a recruitment file; one member of staff is employed by the company but works at other sites. However, it was not possible to check the details of their employment and ascertain whether a CRB had been received. Staff are not attending formal meetings to discuss issues affecting the home. There is no effective quality audit system in place. It is also recommended that there is a qualified first aider on each shift. Accident forms were not being kept in resident’s files and there is no system to audit these. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 7 The practice of staff and others using the kitchen as a thoroughfare continues to present difficulties and issues around hygiene. 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 Manor House DS0000001479.V293878.R01.S.doc Version 5.1 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.V293878.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 6 Prospective residents have sufficient information to help them make an informed choice about The Manor House. Residents and/or their relatives can visit the home before deciding about admission. Residents do not move into the home until their needs have been assessed and the home is sure their needs can be met. Intermediate care is not provided at The Manor House. EVIDENCE: The Manor House provides detailed information to prospective residents and their families. Brochures, available on request, contain the Statement of Purpose and the Service User Guide. Residents are invited to look round the home before deciding to move in. Some people spoken to said they, or their relative, had done this before coming to stay. On the visit people are given an opportunity to have a meal and chat with residents and staff. All residents are offered a trial stay, before having to make up their minds to stay. The manager said the duration of this The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 10 is dependent on circumstances, but would usually be for a minimum of six weeks. As a general rule, it would be at this stage that a review is held. This is used as a formal setting for the resident to make a final decision and to make sure their needs could be met. Staff in the home were able to give examples when this had worked and other examples of when a different procedure was brought in when either the resident didn’t settle or there were apparent difficulties in meeting specific needs, which could not have been predicted on the initial assessment. The manager or her senior staff visit prospective residents and carry out an assessment of need to make sure their needs can be met at the home. A decision to admit someone is made once all the pre assessment information is gathered. Emergency admissions are avoided where possible. It would appear from discussions with staff and residents that admissions are well planned and organised to make the move as calm and relaxed as possible. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Residents and their representatives are involved in the completing of care plans. A significant amount of work has been done to bring the care plans up to date and they now give clear information about the needs of each resident and how these will be met. However, some key information was missing in some of the files examined. Staff approach and treat residents in a respectful and dignified way. Resident’s health care needs are met. The record of medications had not been completed accurately and did not reflect the drugs given. This could compromise the health and welfare of residents. The storage of drugs was good. EVIDENCE: Staff and management had clearly taken action to bring the care plans up to date and a significant amount of work had been invested. The details give a clear indication of the level of input residents need and give specific The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 12 information to staff to make sure there is a consistent approach to care practice. Information relates to night and day time routines. The reader is informed about the individual’s preferences, an insight into their lives prior to admission and their current needs. In some instances residents had signed their own agreements. Some residents are totally reliant on staff to maintain their self-image. This is handled sensitively by staff. All residents met on the day of the visit were appropriately dressed for the weather and attention had been given to their hair and grooming. The manager must make sure that residents are weighed regularly, according to their needs, and that the weight is recorded in the individuals file. Residents said staff were ‘kind’ and ‘good people’. District nurses visit the home regularly and are willing to discuss any resident with the staff and advise on medical issues. One of the inspectors took the opportunity to talk to a visiting doctor. He confirmed three practices were looking after the residents at The Manor House. There are male and female doctors available and that he saw residents in private. All residents are taken through an annual health check and this made sure all residents were being reviewed with regard to their health and welfare. The doctor said staff acted appropriately and he felt all his visits were necessary and that staff knew when medical attention was required. He said the staff in the home were committed to their work and that they took extra steps to make sure people were comfortable and well cared for if they were experiencing the ‘end of life’. All residents had been seen by the visiting optician and dentist. Chiropody treatments were being recorded and residents had access to services as required. None of the current residents had pressure sores. Staff were able to demonstrate their understanding of appropriate care in this area during discussion. Risk assessments are in place to account for all aspects of care. Medication was being stored correctly and staff were familiar with the correct procedures when giving prescribed medicines. However, the medication record had not been completed accurately and did not reflect the medication given on the day of the visit. None of the current resident group takes responsibility for their own medication. However, this is determined by assessment and if appropriate the necessary safeguards are put in place. Staff have contact with the continence advisor for a number of residents. They work alongside the mental health team where there are associated problems. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 13 It was clear during the inspection that staff have a good grasp of the complex needs of residents and are able to overcome difficulties by working at the pace of the resident involved, taking into account their wishes and welfare. Staff showed they had a good understanding of what the rights of residents were and how they were able to respect dignity and privacy. Staff were seen to knock on doors before entering. Residents said this was usual practice. Staff use preferred names when talking to residents. Residents later confirmed they had given staff permission to use their shortened names and that they liked the relaxed atmosphere. On admission residents are asked how they would like to be addressed and this is recorded. Residents commented on the manner in which they were spoken to and one resident said ‘we are treated well and although we forget things and can’t look after ourselves anymore we aren’t treated like children.’ Mail is given to residents unopened. If assistance is required this is offered at the time. Residents have full use of the office telephone if required. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The home provides a good range of activities tailored to meet the differing needs and abilities of the residents. The staff, as far as possible, encourage residents to retain their involvement with the local community. Residents said they were encouraged to maintain contact with family and friends. Residents said they were satisfied with the meals. Food provision is satisfactory. Fresh produce is used and home baking is regularly provided. EVIDENCE: A range of activities are available at the home. They are provided by both the care staff and outside entertainers. The staff organise bingo, quizzes and games sessions. Outside entertainers provide sing-along and exercise classes. On the day of the inspection a visiting entertainer was providing exercise and music activities. The feedback from residents was very positive; those who choose to take part thoroughly enjoyed the sessions. Residents who chose not to were not pressured to get involved. Staff are sensitive to the needs of residents and promote one to one time where appropriate. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 15 A number of residents liked to organise their own activities and chose to spend much of the day in their bedrooms. One service user spoken too liked the fact that he could use the privacy of his bedroom to read and listen to the radio. Staff are keen to introduce new ideas and use their imagination when thinking of age appropriate pastimes. Residents said they could receive visitors in private and at a time that was convenient to them. Staff are aware of the safety of residents and are careful to ensure visitors are welcome and do not compromise resident safety. Where there are potential difficulties they involve other agencies, e.g. advocacy, social services or a third party as necessary. Notwithstanding this, staff were seen liaising with family and friends in an involving way and promoting openness. A three-week menu is in operation at the home. The menus are produced following discussions with the residents and the staff. The menus reflect the changing seasons. A good variety of fresh produce is available and fresh fruit was provided on each of the dinning tables. This is good practice. Residents are offered a choice at all meals and a number said they enjoyed a cooked breakfast. Drinks and snacks are provided throughout the day and night. One of the inspectors joined the residents for lunch. Again positive feedback regarding the meals was provided. The meal was tasty and well presented. The staff were on hand to provide any assistance required and offered residents a choice wherever possible. Two cooks are employed on a rota to provide the breakfasts and lunch. The care staff provide the tea. All the cooks and care staff have completed Basic Food Hygiene training. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents can be sure that their rights are protected and that they are safe from abuse. EVIDENCE: The home has a Complaints policy and procedure in place and this is given to all residents with a copy displayed on the notice board. Staff are all aware of the complaints procedure and know what to do if they receive a complaint. Two complaints, raising similar issues were received recently by CSCI. Until now there had been no complaints. Both complainants were named to the CSCI but wished to remain anonymous to the home. The registered provider conducted an investigation and provided a written outcome to the CSCI. No further action is required. An Adult Protection Policy is in place and staff have received training recently. The manager is confident that staff will recognise the signs and symptoms of abuse and know what to do if they suspect it. The training, received the day before the inspection visit, had reinforced existing knowledge and staff had enjoyed the interaction with other homes and the sharing of good practice. The manager and registered provider encourage relatives and third parties to become involved in the overseeing of resident’s personal money. At the time of the visit, only one resident needed direct assistance with finances. A detailed record is kept of any transactions and where purchases are made, a receipt is filed. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 and 26 The majority of requirements from the last inspection have been addressed therefore improving the overall appearance and usage of facilities. Work required is listed at the end of this report. EVIDENCE: A full building inspection was not undertaken during this visit. However the inspector did check the progress made with regard to the outstanding requirements and recommendations from the last inspection. The carpets in bedrooms 1 and 2 have now been replaced together with the floor covering in the ground floor toilet. Liquid soap and paper towels have been provided in all areas where clinical waste may be handled and a pedal bin provided in the sluice. Colour coded cloths are now being used. Commodes have been repainted. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 18 The majority of the wardrobes in service user bedrooms have been secured with the exception of bedroom 14. This must be addressed. The manager has made some progress in separating the clean and dirty areas in the laundry. Doors have been placed on the linen cupboard which provides some protection. Further changes cannot be undertaken without carrying out structural changes. Overall the home was found to be clean and tidy. Attention is given to the floor coverings to reduce the existence of malodours. Staff must continue to be diligent in this area. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The numbers and skills mix of the staff were adequate to meet the needs of the current resident group. Staff on duty had a good working knowledge of the resident group and there is an atmosphere of teamwork, where staff work together. Staff have received training to enhance their knowledge. Future training is planned to make sure staff are competent and can deliver the care required. EVIDENCE: The Manor House is registered to look after a maximum of thirty residents at any one time. The number of staff on each shift, during the day and night time is sufficient for the current needs of the residents living at the home. However, the manager is mindful that where needs change then staffing levels must be reviewed to take this into account. If there is a shortfall in staff available due to absence, existing staff are keen to provide cover, therefore agency staff are not used. Since the last inspection four members of staff have left. The home employs a team of domestics. It was clear from the attitudes of staff that they saw their roles as important and were flexible enough to change their work patterns if there was a need. Everyone said they were happy to cover for colleagues and that ‘they all The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 20 mucked in – even the manager’ to make sure the residents did not want for anything. They gave examples of when they had worked together to overcome illness amongst the residents or when colleagues were off themselves and they were deployed into different roles to cover. Staff were proud of the care they provided. All, but one member of staff have had police clearance. Any issues highlighted from this were dealt with by the organisations legal department and if necessary risk assessments were put in place. Three recruitment files were seen. One member of staff did not have any recruitment details in the home, as their main employer was off site. This must be rectified and the usual checks must be made to make sure they are suitable for the job. The manager agreed to implement this without delay. It is recommended that the manager reintroduce staff meetings on a more formal setting. Her comments were acknowledged, however, as the situation stands at present there is no evidence to show that any discussions or information is shared to benefit the running of the home. The manager has worked at the home for eleven years; the deputy for seventeen years and a few carers are also longstanding members of staff. This provides some consistency. The manager agreed and discussed the difficulties associated with the promotion of current practice and additional training. At present only one member of staff has a National Vocational Qualification. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 and 38 The home is managed appropriately and the interests of the residents are seen as important to the manager and staff. Systems are in place to make sure that the health and safety of the residents and staff is protected, however this is compromised at times by some practices. EVIDENCE: The issue of staff, residents and visitors using the kitchen as a thoroughfare is still a problem. The manager must remind everyone that the kitchen is a highrisk area and access must be restricted. Some staff were seen using the kitchen as a short cut to access other parts of the home. Other visitors entered the kitchen to announce their arrival and it was clear that there were no restrictions on who could enter the kitchen or that protective clothing must be worn. Staff confirmed that this practice was common. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 22 The manager has many years experience working in the care field. Staff meetings are not held formally and the reason for this was explored during discussion with the manager. These should be reintroduced to create an environment where issues can be discussed and shared. The meeting should be organised by using an agenda and there needs to be a sharing of information. Minutes of these meetings should be made available for those who cannot attend and be agreed as a true record. In this way the manager can demonstrate the involvement of the staff team and how decisions affecting the home are made. It was not clear whether staff supervision sessions are in place with written records and agreements. However, everyone spoken to said that the manager offers good support to them and is very approachable. Good interactions were observed between the manager, residents, visitors and staff. Residents spoken to said that they are happy at the home and that they knew who to talk to if they were worried or dissatisfied. Some said that nothing is too much trouble for the staff and that they are always willing to be helpful. The records seen concerning monies handled on behalf of one resident were correctly maintained. Staff have received Health and safety training. However, it is strongly recommended that there is a qualified first aider on each shift. There is a call system available in all parts of the home for residents to summon help. Fire bells and emergency lighting are tested weekly with records kept of these. Accidents and incidents are being recorded. However the format used does not allow for forms to be numbered or a copy to be placed in the residents file. Where staff do not witness an accident, a record should be kept of when the person was last seen and by whom. An analysis should be kept of all accidents so that any patterns or trends can be identified. This was discussed with the manager and a suitable solution agreed. An effective quality audit system must be introduced to make sure that systems and services are reviewed and improved. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 17 3 18 3 3 3 X X X 2 3 2 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 x x 3 x 2 2 The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement Care plans must set out in detail the action that needs to be taken by staff to make sure that all aspects of health, personal and social care needs of the resident are met. Care plans, wherever possible, must be signed and agreed by the resident and/or their relative or representative. This requirement remains outstanding from 31 December 2005. 2 OP9 13 (2) All medication record sheets 06/07/06 must be fully completed in accordance with guidelines from the Royal Pharmaceutical Society of Great Britain. This requirement remains outstanding from 31 December 2005. 3 OP24 13 All freestanding wardrobes must be secure. This requirement remains The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 25 Timescale for action 05/07/06 02/07/06 outstanding from 7 February 2006. 4 OP26 13 (3) Work is required in the laundry to make sure clear division between clean and soiled linen. This requirement remains outstanding from 7 February 06. 5 OP29 19 Sch 2 All staff must have a recruitment file. These must contain a completed application form, two written references, evidence that a CRB/POVA check has been carried out and a photograph of the staff member. This requirement remains outstanding from 7 February 06. 6 OP32 21 Staff meetings must take place on a regular basis, with minutes of the meeting kept for future reference. This requirement remains outstanding from 7 February 06. 7 OP33 24 An effective quality audit system 07/10/06 must be introduced to make sure that systems and services are reviewed and improved. This requirement remains outstanding from 7 February 06. 8 OP38 17 Sch 4 A copy of the accident record must be held in the resident’s file. This requirement remains outstanding from 7 February 06. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 26 05/10/06 02/07/06 07/07/06 05/07/06 9 OP38 13 Staff must not enter the kitchen unless they are wearing protective clothing, such as a tabard, apron or white coat. This requirement remains outstanding from 7 February 06. 02/07/06 10 OP38 13 Staff must not use the kitchen to access other parts of the home. This requirement remains outstanding from 7 February 06. 02/07/06 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 OP38 OP38 Good Practice Recommendations There should be a qualified first aider on each shift. Where staff do not witness an accident, a record should be kept of when the person was last seen and by whom. An analysis should be kept of all accidents so that any patterns or trends can be identified. The Manor House DS0000001479.V293878.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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.V293878.R01.S.doc Version 5.1 Page 28 - 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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