Inspection on 02/02/07 for The Manor House

This inspection was carried out on 2nd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 31/03/09

The Manor House 10/09/07

The Manor House 14/12/05

The Manor House 25/11/05

The Manor House 13/09/04

The Manor House 06/04/04

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

CARE HOMES FOR OLDER PEOPLE The Manor House The Manor House 6 Bawnmore Road Bilton Rugby Warwickshire CV22 7QH Lead Inspector Mrs Suzette Farrelly Key Unannounced Inspection 2nd February 2007 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 DS0000032248.V300643.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Address The Manor House 6 Bawnmore Road Bilton Rugby Warwickshire CV22 7QH 01788 814734 01788 814734 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Pinnacle Care Ltd DE(E) - 26 26 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (20), of places The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2005 Brief Description of the Service: The Manor House is a mature building with parts dating back to the 16th Century, and is set in its own grounds, adjacent to the village green, in Bilton, Rugby. The Manor House was converted from a private dwelling into a care home in 1985. The Manor is registered to take 26 older people with dementia. The Manor House has twenty-two single bedrooms, twenty-one of which have en-suite facilities. One of the two double rooms also has en-suite facilities. There are two communal bathrooms and four communal toilets. The home has three large communal lounges with south facing gardens. The accommodation is over two floors reached via two passenger lifts. The local shops and amenities are a 2-minute walk away. The fee for living at this service varies from £395 to £650 for a large individual room with basic en-suite facilities. There are extra charges for toiletries, chiropody, hairdressing and some activities such as outings. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the first for this year. This report was written using information received by us from the home throughout the year, the Pre Inspection Questionnaire sent to us by the manager, comments from residents and their relatives, and this visit. The home offers a reasonable service to the residents. In some areas, such as choice and the type of food available is very good, whereas other areas such as staff required needs further attention. During the visit three residents were ‘Case Tracked’ this involves reading their care profiles, discussing their care with them and the staff. It also involves examination of their individual rooms and facilities available for them. Other areas examined included staff records, health and safety records, discussion with the manager, domestic and cook. What the service does well: The manager was asked ‘What do you think the home does well in?’ she stated that she felt that the: ♦ Care staff are very kind and attentive to the residents and ensured that all their needs were met. This was also seen during the visit to the home and three residents stated that the staff ‘Were always nice and kind’. Residents are given choices in areas such as what they ate and times for getting up and going to bed. This allows residents to have some control over their life and it was observed that residents are assisted to make choices. The management of medication is good and residents receive their medication as needed. The care staff although often busy have time to chat to the residents and consider their moods and the way they are feeling. It was noted that there was a lot of fun occurring between residents and staff with jokes being told and it was easy to tell that the staff and residents knew one another well. ♦ ♦ ♦ The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 6 It was noticed during the visit to the home that meal times were a social affair with staff and residents eating together. There was a good atmosphere and the residents were offered a choice of three meals. Staff training is good and all staff are offered the opportunity to do ‘Dementia Care Training’ and other courses to increase their knowledge and practice while at work. What has improved since the last inspection? The manager was asked ‘What improvements have been made?’. She stated the following: ♦ ♦ There has been an improvement in the quality and variety of food offered at all meal times. This was also seen during the inspection. All towels have been replaced in the home, there are now sufficient numbers for all residents and it also allows towels to be replaced in communal toilets and bathrooms every two hours. There has been a replacement of a number of items of furniture such as the dining room tables making the environment more homely and comfortable for the residents. ♦ The home was found to be cleaner and the manager with the cleaner and care staff address areas where unpleasant smells occur quicker and more efficiently. This makes the environment nicer to live in. There has been an ongoing programme to re-decorate all areas and replace worn carpets and furnishings, many areas look clean and bright and inviting. Staff training in fire and health and safety has improved and staff confirmed this. What they could do better: The manager was then asked ‘What could improve?’ she felt the following areas needed attention. ♦ ♦ That the quality of the care profiles could be improved so that all the information about residents is clearly recorded and up to date. That the ‘Best Friend’ scheme, this is where a carer is given up to three residents to get know well and to form good relationships with families, could be improved to ensure that all staff are involved and are confident in this role. This would improve communication with residents and their families. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 7 ♦ The bedrooms could be improved further. The manager felt that the use of valances, the finishing touches when tidying these rooms and ensuring that there are personal items form all residents available would make these areas inviting and more comfortable. Further training for staff to ensure that they are fully up to date with changes in practice and have a good understanding enabling them to give an excellent service to the residents and their families. ♦ Further training in recognising and responding to actual and allegation of abuse is required. One staff member spoken to was confused about this process. The policies and procedures for dealing with abuse also did not reflect the practice described by the manager. This could result in confusion and the wrong actions being taken. The home would also benefit from more staff to ensure that the social needs of the residents are properly dealt with. At present the care staff do multiple tasks including caring, laundry and some cleaning in the evening. This takes them away from other activities they could be doing with the residents. The home would also benefit from a designated laundry person to ensure that the quality of laundering is improved. Relatives had commented that clothes are ruined and lost. 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 DS0000032248.V300643.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Manor House DS0000032248.V300643.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality in this outcome area is good. All residents have a full assessment before being admitted to the home. This ensures that their needs can be met. This judgement has been made using available evidence including a visit to this service. Standard 6 was not assessed, as the service does not provide intermediate care. EVIDENCE: Three residents’ records were seen and one pre-admission form for a resident that the manager visited on the day of the visit. Information contained within these documents gave clear indications of the need of the residents and assisted the manager to decide if the home could meet the needs properly. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 10 The residents’ records showed that risk assessments and some care plans were developed from this initial assessment. The manager discussed the pre-assessment and has suggested some changes to ensure that a good medical history and personal background is also properly included. This will ensure that not only the immediate needs are met but that the home is also aware of possible problems that may occur. There was evidence that this had been achieved with the pre-admission visit carried out on this day. The Manor House DS0000032248.V300643.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is good. The residents’ health, and personal needs are clearly recorded and met by the staff. The residents social care needs are not always recorded. The management of medication is good and ensures the safety of all residents. All residents are treated with dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three resident were ‘case tracked’ and their care profiles were examined. All had risk assessments concerning skin care, the risk of falls and nutrition. Other risk assessments were available for specific areas such as the risk of leaving the home, challenging behaviour and medication administration. These risk assessments are revisited monthly and dated, changes are made where and when necessary. Staff do not initial or sign their name when checking the risk assessments, this would make it difficult to ask for further information if required. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 12 The information concerning the care required by each resident was found in ‘Strengths and Abilities’. This gave a clear indication of what help the resident required and what staff need to do. It was difficult to determine how changes would be made as it was a ‘running commentary’ with one issue immediately after the other. Staff interviewed were asked about the care of one particular resident ‘case tracked’. Both staff were fully aware of this residents’ needs and the actions they needed to take to ensure that the resident remained healthy and that the needs identified were met. Their understanding of this residents’ needs matched the care described in the profile. Good records were available from the GP and District Nurse visits, however, some of the information from the District Nurse was not written into a care plan. Staff were aware of the needs of this resident. There is a separate file available for visits to or by the dentist and optician. These records contain the names of all residents together; this would cause an issue of confidentiality if the information needed to be shared. The daily records are completed as required. The information in the daily records does not give a clear indication of all the areas of care given during that period. This would make it difficult to determine if care was completely given or not. The manager is aware of this and intends to give clear instructions to staff on the expected quality of daily records and what they need to contain. The morning medication round was observed. The medication is administered from the medication room. Each resident is taken his or her medication on a tray with a glass of water. The Medication Administration Records were properly recorded and other records associated with return of medication and the management of Control Drugs were also kept properly. The home does not keep excessive amounts of medication and the medication room was tidy and well organised. It was seen that there are a lot of ‘build up drinks’ for those residents who do not eat well. The manager is aware of this and intends to ensure that all residents who require these are given them as needed and that they are also used with in their daily meals. It was observed throughout the visit that residents are treated with dignity and respect. Staff referred to residents by their preferred names and always knocked on bedroom doors before entering. Staff were seen sitting with residents, listening to them and responding in an appropriate way, reducing anxiety and at times having fun. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 13 Residents spoken to said that staff always help them and that they enjoy living at the home. One resident stated that she sometimes felt rushed by the staff in the morning. At this time there are no residents who have different cultural needs. This area was discussed with the manager who described how these needs would be met and the training needs of staff such as cultural awareness. Sexuality and the understanding of relationships between residents and residents and their families were also discussed. The manager stated that she believed that the staff would be sensitive but also said that further training and support would be needed to improve this area. The Manor House DS0000032248.V300643.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality of this outcome area is adequate. The lifestyle experience of the residents does not always match their expectations nor satisfy their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Once a month there is a regular activity such as, ‘Movement to Music’ and ‘Sing-a-Long’. There is also an outing about once a week; five residents went out to a ‘Pub Lunch’ on the day of the visit, which was enjoyed by all. Day to day activities is dependent upon the care staff, both staff and residents said that this does not happen as often as they would like. There was no activity programme available. There is an activity room with a variety of materials such as paints, paper, board games, but these are not used on a regular basis. This was discussed with the manager who said that some staff have good ideas for activities, but time was a major factor. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 15 Residents’ individual likes and dislikes and expectations were not clearly recorded in their profiles. One resident told us that she used to draw and still would like to do this but did not have a pencil and paper. This was shared with the manager. During the visit some residents watched television and others were seen sitting around the other lounge at times talking to each other or staff or sitting quietly or sleeping. Staff, where able to spend individual time with some residents, but those residents who did not request attention were only attended too for personal care. All residents have the opportunity to go out of the home to pub lunches, shopping and one resident visited the local church on a regular basis. Staff interviewed felt that they had insufficient time to do activities and would like to have more time to sit with the residents and do ‘nice’ things. There are no restrictions to visiting time and relatives are made welcome. One relative spoken to prior to the inspection visit said that they visited the home and were always made welcome. Two residents stated that they see their families regularly and enjoy these visits. A meal was eaten with the residents at lunchtime. The dining room is spacious and welcoming with large windows that let in a lot of natural light. The tables were laid with tablecloths, place mats, cutlery and condiments. Each resident was offered a choice of three separate main meals. Those residents who could not verbalise their choice were shown the different food available to assist them with their choice. Staff ate their meal with the residents and where required assisted residents to eat, mainly encouraging the residents to fed themselves. There was a good social atmosphere with residents chatting amongst themselves and with staff. A resident asked for a drink of wine, as the order had not been delivered the manager sent a carer to the local shop to buy some and then offered this to all the residents. The kitchen was visited, it was found to be organised and clean with a good stock of fresh, frozen and dried foods. On the 24th January 2007 the home had a visit from Rugby Environmental Health who stated that the insectocuter (for killing insects) was not working and that the work surfaces and shelving has edging strips missing. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 16 Paint is also flaking on wooden surfaces. The cook and the manager stated that the registered provider had been to examine the kitchen and it is planned to have a new kitchen fitted. The date for this has not yet been agreed. The Manor House DS0000032248.V300643.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality of this outcome area is adequate. Residents and their relatives are not always confident that their complaints will be listened and acted upon properly. Staff knowledge and policies and procedures for the protection of adults are not clear putting residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We have received one complaint since the last inspection. This was passed to the management of the home to investigate. The complaint came to us because the family of a resident felt that their concerns were not being properly listened to nor acted upon. The manager of the home, who has only recently taken her post, stated that she takes concerns and complaints seriously and would respond immediately to both residents and relatives. The Complaints Procedure was seen in the entrance area of the home and it is also available in the ‘Statement of Purpose’. The person reading this is directed toward making the initial complaint to the Commission rather than the home, this was discussed with the manager who stated that she would address this with her manager. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 18 One staff member who has worked at this home for four months did not know the full procedure related to the protection of adults and was unsure of the finer details in relation to abuse. The policies and procedures in the home did not reflect the understanding of how to deal with suspected or actual abuse as described by the manager. This could cause confusion and the wrong actions being taken. There has been no reported abuse in the home since the last inspection and residents spoken to state that they felt safe. There was a pleasant and open atmosphere in the home with residents and staff sharing jokes and laughing together suggesting that staff care for residents and are kind. The Manor House DS0000032248.V300643.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The quality of this outcome area is good. The residents live in a safe, wellmaintained environment that is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A selection of residents’ bedrooms were seen including those who were ‘Case Tracked’. Most bedrooms were clean and tidy and free from smells. Two bedrooms had an unpleasant odour. The manager was aware of this and has plans in place to ensure that it is dealt with. Although the bedrooms are pleasant the manager wishes to improve the appearance and has requested new valances and has instructed staff how she wishes the rooms to be left in the morning. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 20 The home has two large lounge areas leading into one another; both these areas were pleasant and clean with a variety of seating to suit all residents. The carpets are highly patterned and some residents with dementia were seen try to pick bits off the pattern. It is recommended in homes that care for those with dementia to have carpets without patterns as they can be mistaken for insects and other items. There is also a large area between the second lounge and dining are this has an attractive fireplace and suitable seating. The dining room as stated earlier in this report is large and bright and very welcoming. The entrance to the home is at the rear and is opened using a key. The reception area is light and pleasant with no distinctive smells. The laundry is in this area, it was found to be tidy, however washing was in the washing machine and both tumble driers. Care staff are responsible for the laundry and it appears that they have insufficient time to do this properly. Relatives have remarked on comments sheets sent to them by the home that the laundry is an area of concern. Discussion took place with the manager regarding the use of cloth towels in the communal bathrooms and toilet areas for drying hands. A form was seen that should be signed when the towels are changed. These are changed two hourly to maintain infection control, however the records showed that this only occurred when the domestic was in the home and one member of care staff. This makes the practice of using non-disposable towels a possible hazard. The home has recently had an out break of scabies, during this time the management must consider if using non-disposable hand towels is appropriate as scabies is often transmitted in this manner. This was discussed with the manager who stated that she would action this and discuss with the infection control nurse. The Manor House DS0000032248.V300643.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality of this outcome area is adequate. There are not enough staff on duty to ensure that all areas and tasks required each day are carried out effectively. Staff require further training to ensure they are competent to do their job and protect residents at all times. The employment procedures ensure that only staff who are safe work with the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff records were examined and found to contain all the information required to ensure that staff who are employed are safe to work with vulnerable adults. A separate file is available with all the staff Criminal Record Bureau and Protection of Vulnerable Adults checks. Two staff were interviewed and it was found that their understanding of the protection of vulnerable adults was incomplete, further training and support is required to ensure that this area is addressed. There are usually three care staff on duty during the morning and afternoon and two care staff at night. The care staff are also responsible for the laundry and some cleaning tasks in the evening after the domestic leaves. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 22 The registered provider and registered manager need to assess the time care staff spend doing non-caring activities and ensure that there are sufficient care hours available to meet not only the physical needs of residents but also their social and recreational needs. The manager is included on the duty rota and works from Monday to Friday from 8.30 to 17.30. She does assist with care activities in part to ensure that staff carry out their duties properly. The home employs one main cook and a further two cooks to fill in for days off and holidays. The cook is available for breakfast and lunch and prepares the evening meal. However care staff are responsible for finishing this off and serving it. There is a domestic who works until 14.00 hours and then the care staff clean up after teatime and the night staff vacuum the lounges and communal areas. The manager felt that the cleaning could improve and that there are areas of the home that are not cleaned as frequently as they should be. The registered provider and registered manager should assess the number of cleaning hours required and employ suitable staff to carry out this job. Residents spoken to stated that although the staff were kind and assisted them when needed they were also very busy and at times they had to wait or felt rushed. Relatives who replied to the home’s comment cards and who were spoken to by us also stated that they felt there were not enough staff on duty at times to ensure that all residents needs were met. The Manor House DS0000032248.V300643.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 The quality of this outcome area is good. The home is managed well in the best interest of the residents. Health and Safety issues are maintained and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has only been in post for four days and has already instigated changes in practice to improve the environment and service to all residents. She has worked for Pinnacle Care Ltd for two years as a deputy manager in a sister home. She is suitably qualified and has achieved her National Vocational Qualification Levels II and III and Level IV in Care Management, and has the registered Managers Award. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 24 She has also attended course in Dementia Care, Risk Assessment, Medication Management, Health and Safety and Food Hygiene. The manager stated that she is waiting for the forms from us to register as the manager of The Manor House. She is planning to have individual meetings with all relatives to discuss and review care and to discuss their views. She will also organise a Relatives Meeting in the near future. She is also planning to commence monthly staff meetings. The previous manager sent comment cards to all relatives regarding the running of the home; these had some interesting information about what relatives think the home does well and where improvements are required. An assessment of these comments had not been completed and no actions taken to address these comments. Audits of medication are carried out monthly along with other audits of the home. Daily room audits are carried out and any repairs are recorded in the maintenance book. The maintenance person on completion of the work signs this. Although there are audits carried out in the home, there is no clear indication what is done to improve areas and the time scale required. Staff records showed that staff had received regular supervision up to the point that the past manager left in late 2006. The new manager is going to commence supervision every two months for all staff. Supervision records examined were good and contained information discussed at the meeting and actions to be taken. Staff spoken to said that they liked the supervision as it was their time to discuss issues of concern. The home does not manage the personal finances of residents. Any extra money spent is invoiced at the end of each month. The health and safety records were examined and these were found to be up to date and in order. The Manor House DS0000032248.V300643.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 3 X 3 The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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(2) Requirement The registered provider and registered manager must ensure that care prescribed by the GP or District Nurse is recorded onto a care plan and changed as required. The registered provider must ensure that the information from visits by the dentist and opticians are recorded clearly in the individual resident records. The registered provider and registered manager must assess the needs of residents in regard to the type of daily activities they would enjoy and to ensure that there is a suitable selection of activities for all residents in the home. The registered provider must ensure that the complaints procedure direct residents and relatives to make a complaint to the home manager first if appropriate before going to higher management or us. The registered provider must ensure that all staff are aware of the correct procedure for DS0000032248.V300643.R01.S.doc Timescale for action 31/03/07 2. OP8 13(1)(b) 31/03/07 3. OP12 16(m)(n) 30/04/07 4. OP16 22 31/03/07 5 OP16 22 31/03/07 The Manor House Version 5.2 Page 27 6 OP18 13(6) 7 OP18 13(6) 8 OP26 13(3) 9 OP27 18(1) 10 OP33 24 residents and relatives to share their concerns and complaints and that these are acted upon promptly. The registered provider must ensure that the policies and procedures related to the recognition of abuse, actions to take in the event of abuse and whistle blowing are up to date and reflect the practice by for the organisation and local social services. The registered provider and registered manager must ensure that all staff employed are up to date and aware of the procedure for recognising abuse and what to do in the event that abuse is suspected or witnessed. The registered provider and registered manager must assess the use of non-disposable towels in communal toilets in relationship to certain infections such as scabies and develop short-term actions to prevent spread. The registered provider and registered manager must assess the amount of time care staff spend doing non-caring duties such as laundry and ensure that there are sufficient care hours available to meet the physical. Psychological and social care needs of all residents. The registered provider and registered manager must ensure that information gained from the monthly audits and relative/resident feedback is assessed and actions to improve the service are developed with suitable time scales and evaluation of success. 31/03/07 30/04/07 28/02/07 31/03/07 31/05/07 The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 28 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 OP26 Good Practice Recommendations An insectacutor should be fixed and other areas on the environmental report actioned. The Manor House DS0000032248.V300643.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 DS0000032248.V300643.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. 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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