Inspection on 22/11/07 for The Manor House

This inspection was carried out on 22nd November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 11/04/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Manor House 1 Walsall Road Willenhall Walsall West Midlands WV13 2EH Lead Inspector Keith Jones Key Unannounced Inspection 22nd November 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 DS0000069001.V355372.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 DS0000069001.V355372.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Address 1 Walsall Road Willenhall Walsall West Midlands WV13 2EH 01902 603 754 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) Jason Harold Horton Mrs Annette Horton Care Home 25 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (25) of places The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 2007 Brief Description of the Service: Manor House is a large Victorian property converted and extended to offer residential care for up to 29 older people. Situated near the centre of Willenhall the property is located near to local amenities and is easily accessible to local transport. There is a courtyard at the side of the property with adequate, offroad parking to the rear of the Home. Accommodation comprises a large sitting/dining room, a smaller ‘quiet’ sitting room, 23 single bedrooms and 3 double bedrooms. The Home currently charges £337.29 for residency; this fee does not include extra service charges for hairdressing, newspapers and dry cleaning. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of The Manor House Care Home was undertaken within a day, by one inspector; the Care Manager and senior care staff, in a professional, frank and open manner. The last inspection report was discussed, and it was noted that requirements and recommendations had been attended to, or were being addressed satisfactorily. On the day of inspection there were 27 service users in residence. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of service users, relatives and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. A full case tracking of three Service Users yielded a valuable insight of policies in action. Records had been correctly filed and stored, with a sample review of the administrative arrangements, confirmed effective management. The Care Manager and staff were thanked for their cooperation and open willingness to contribute to the inspection process. A full verbal report was offered at the end of the inspection. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection of an improving service. What the service does well: There is a friendliness and general ambience in the interactions observed throughout the inspection. There was evidence of a much-improved infrastructural support, led by an enthusiastic management team with an experienced Care Manager, who has the necessary freedom to manage directly, with an experienced senior carer in assistance. The standards of personal care were observed to be of a good quality, reinforced by discussion with residents, staff and relatives. This highly personable attitude and approach to care continues to be appreciated, and welcome by residents and visitors alike. The housekeeping and support services all contribute to the team approach, and are recognised by the management for their efforts. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 DS0000069001.V355372.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,and 5 The quality in this outcome area is good. The Statement of Purpose has been, and continues to be reviewed, in addressing the major issues and reflecting changes. The Home ensures that the admission process is recognition of a joint understanding that residents are aware, and that staff are able to meet expectations, to realise a comfortable transition. Prospective residents and their relatives are able to visit and assess the quality, facilities and suitability at any reasonable time, to meet with staff and management. The Home ensures that prospective residents have the necessary information to enable an informed choice to be made. All residents have contracts of terms and conditions of residence at the home a copy of which is on resident’s files. EVIDENCE: The revised Statement of Purpose represents a much improved and impressive description of the Home’s aims and objectives, philosophy of care and terms The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 9 and conditions, updated to meet the contemporary situation. It is recognised that the Statement of Purpose represents the foundation on which the home operates upon, offering service users and their relatives the opportunity to make an informed choice about where to live. A separate and well-produced service user’s guide serves as an easily readable summary of the Statement of Purpose and supporting information, widely used to inform all interested parties. A large print version would be advantageous. There is an extensive review of policies and procedures underway. The Home continues to deploy a clear statement of contractual agreement, in tandem with the Statement of Purpose, clearly indicates the terms and conditions, which are discussed with service users and relatives prior to admission. Residents’ contracts have been reviewed to offer an easier read facility. Case tracking of three individual residents clearly identified that the Care Manager, or her deputy, at the point of reference, conducts the pre-admission assessment. The documentation was examined and found to be comprehensive, providing a solid foundation for effective care planning. This assessment is produced with the full involvement of service users and family, allowing them to influence the direction of care. The assessment initiates the process of care, each individual having a plan of care, which includes longerterm goals and outcomes. Following an assessment the senior carer assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the individual and any special needs. Likewise the applicants are informed of those facilities and are encouraged to seek clarification concerning the general and specific services available for the prospective service user. Any special needs of the individual were discussed fully and documented, ensuring their individual needs would be met. Case tracking confirmed that a valuable exchange between service users and assessor took place and resources made available. These resources were seen to be an appraisal of staffing skills, equipment and general environment. From discussions with staff and service users it was evident that prospective service users and their relatives are able to visit and assess the quality, facilities and suitability at any reasonable time, to meet with staff and management. Trial periods of stay for prospective residents have been established. At all times relatives were seen to be involved in the process. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 The quality in this outcome area is good. The service users’ assessment provides the base, from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has access to local GPs that visits the Home frequently, and the majority of service users are registered within 48 hours. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The inspector observed the free, courteous interaction between service users and staff based on a level of confidence of essential mutual trust and respect. The provision of a secure and safe medicines administration is managed effectively. EVIDENCE: There was evidence to show that a review of the care process has produced a satisfactory standard of meeting care needs. The pre-admission assessment The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 11 represents the foundation for an informative care planning process. Three residents’ care files were tracked and demonstrated a system of detailed information on the individual, their life style and needs, events and contacts, procedures and actions measured on a daily basis and reviewed monthly. The policy of the home is to maintain service users own GP support wherever practical; otherwise residents are registered with the local surgery. District nursing services are also received, and the home has an established and positive professional rapport. Paramedical support is openly obtained when necessary. Discussions with service users confirmed their acceptance and confidence in the overall standard of care and service given. “ Annette and the staff work extremely hard, and are always ready to help”, ”always well fed with good food, although they could do with more staff” were some of the comments offered by residents. There was evidence that suitable equipment was deployed effectively. Carers were seen to interact with residents with purpose and compassion. The facilities and bedrooms were presented to facilitate privacy for the individual, which included medical examinations and personal care procedures, being performed in private. The administration of medicines adhered to procedures to maximise protection to service users. The reviewed storage system was secure, with satisfactory added security for controlled drugs. Keys to the outer cupboard are to be held by the senior carer. A controlled drug register was examined and found to be in order. The Care Manager was asked to work with the supplier to ensure clarity in matching up dates of issue to administration. There were no residents self-medicating at the time of inspection. Each service user has the opportunity of their own lockable facility in their bedrooms on request. There is an overflow trolley to house new stocks of supplies, which needs securing to the wall. The procedure for handling accidents and incidents was inspected and found to hold a policy of referral for medical/paramedical opinion if in doubt. There were no reported accidents for this inspection period, however the Care Manager was advised to analyse accidents on a 3 monthly basis. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. There was also an observed knowledgeable, and positive attitude by staff towards residents, and feedback from the residents: “Although I travel from London, I am always kept informed” and “ nice home, comfy and friendly” “Mum’s weight has doubled due to the good food, and staff are always cheerful”, were some of the relatives remarks. The Statement of Purpose clearly and openly states that the wishes concerning arrangements after death would be discussed and respectfully carried out. The The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 12 spiritual needs of service users were recorded and observed by the staff, with due respect. The Catholic priest holds a small service once a month; the C/E service is awaiting a new vicar. The Manor House DS0000069001.V355372.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 and 15 The quality in this outcome area is good This judgement is based on discussions with service users, staff and examination of records in relation to social activities undertaken and general observations during to course of the inspection. The home had a relaxed and welcoming atmosphere where people were encouraged to continue with their individualised lifestyle. Those who wish to bring in personal possessions are encouraged to do so. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The Home operated a four-week menu providing a varied, nutritional and well balanced diet; service users had a choice of meals and were also offered alternative choice. Special diets were accommodated with the staff making every effort to engage with service users to discuss personal preferences. Staff were seen to offer discreet assistance to those who required it at lunchtime, when a very attractive luncheon of chicken or faggots was presented. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 14 EVIDENCE: Discussions with residents and staff identified a relaxed atmosphere in which the residents’ needs were respected. A routine exists to establish a framework for managing the home, not as a regime for residents to comply with, but for a point of familiarity. Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are routine events to the day they could relate to. The Home has a part time activity staff member, for six hours a week, organising a variety of activities with occasional trips to the town and community events. This Christmas there are numerous events arranged including Pantomime and parties. A monthly Newsletter has been set up to help residents make choices and to get involved. Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. During the course of the inspection staff were observed to interact with the service users in a positive and polite manner. The standards of catering offered a satisfactory service, to which service users spoken to were complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and suitable choice. A very pleasant lunch was served during inspection, with choices available, served in a pleasant, newly decorated dining room adjacent to the lounge area. Three meals were provided daily, with hot and cold beverages and snacks available throughout the day. Menu cards were noted on each table. Residents that were interviewed confirmed that that the quantity and quality of food provided was good. Individual preferences were recorded in assessment and conveyed to the catering staff, whom met with, and discussed their requirements. It was confirmed that the cook knew each service user, and some of the relatives. Diversity of diet was discussed with the cook on the day, who indicated an awareness in meeting individual needs. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of the resident. The Manor House DS0000069001.V355372.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): 16,17 and 18 The quality in this outcome area is good It is the clear policy that Manor House enables any staff member, service user, service user representative, or visitor to the home to lodge any complaint or concern they may have about any aspect of their service. The care manager showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. EVIDENCE: The complaints procedure was presented within the Statement of Purpose and contract, displayed in reception, and identifies the registration details. The complaints file was examined and found to be satisfactory. There was no outstanding issue at the time of inspection. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. This process would be enhanced with a record and analysis of all complaints, sectioned into concerns, complaint and allegations. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 16 Advocacy service is encouraged and available to those who require it as indicated in the service user guidelines. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. The Care Manager showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. The policy and procedure for handling issues of abuse (Safeguarding) continue to need an update and reappraisal. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. Booklets from the General Social Care Council’s Code of Conduct are given to all staff to help reinforce the induction and training programmes. The Manor House DS0000069001.V355372.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): 19,20,21,23,24,25,26 The quality in this outcome area is good. This judgement was based on discussions with service users, staff and a tour of the premises. There has been extensive refurbishment from the last inspection, which will continue through to the Spring. The home is well appointed to meet the needs of an elderly population of service users in providing a safe and comfortable environment. On inspection, bedrooms were highly personalised with most displaying service user’s own furniture, and with personal belongings. All communal areas are of a good standard, offering social as well as private reflection, as the mood takes. The overall environment was found to be safe for service user’s comfort within risk assessed limits. The domestic services in the home were seen to be of a high standard, with no evidence of unpleasant smells or unsightly debris anywhere throughout the inspection. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home is well appointed to meet the needs of an elderly population of service users. A traditional large town home setting provides a safe, comfortable, friendly and homely environment. External access is satisfactory for visitors parking. Recent work on clearing the patio area was noted, ready for use in the Spring. New garden furniture is on order. On admission the Care Manager assesses each individual service users’ needs for equipment and necessary adaptations. Efforts had been made to provide a homely atmosphere and the décor in most areas of home was found to be of a high standard. Internal access was facilitated with sufficient fittings of hand and grab rails in adequate, well-lit and airy corridors. Continuing re-decoration and recent up-grades were inspected and found to be representative of a full refurbishment programme, establishing a long-term commitment to improve services and establish Manor House’s good quality standard of care. The Home is preparing a development programme on refurbishment for 2008/09 for the next inspection. Bedrooms were well maintained to meet service user’s personal preferences. On inspection most bedrooms were highly personalised, with most displaying service user’s own furniture, and personal belongings. It is the policy that on bedrooms becoming vacant, that each room is reappraised for redecoration, as confirmed during the Inspection. There is throughout a good standard of furnishing complimented with a variety of personal belongings. At the time of inspection several bedrooms were being upgraded, redecorated and refurbished. It was noted that some wardrobes had not been secured to adjacent walls following redecoration. The remote, pendant call alarm system was satisfactorily tested, and service record checked with PAT reports. Communal spaces are furnished to present a homely atmosphere, a high standard, offering social as well as private reflection, as the mood takes. The redecorated lounge allows activities to be presented in very pleasant areas of the home, with furniture and fittings of good quality. The newly decorated dining area is well furnished and presented to provide a conducive environment to enjoy a good meal. Staff supervision is available throughout the day. Corridors are wide enough for wheelchair access, well lit and with sufficient handrails. The domestic services in the home were seen to be of a high standard. The service users and relatives spoken to remarked that they find the environment always very clean and conducive. The home presented a clean and pleasant, The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 19 odour-free atmosphere, much to the credit of the housekeepers. To complement the presentation there were numerous floral and decorative displays. During the period of refurbishment the Care Manager was advised to increase hours to accommodate extra demands on domestic services. The heating arrangements throughout the home are by central heating with guarded radiator convection. The laundry area was clean and very well organised; procedures were in place for coping with soiled/infected linen with provision to minimise handling, and cross-infection. COSHH signs were evident. Chemical cleaners were used appropriately throughout the home, and were seen to be secure and under COSHH recommended practices. The kitchen was inspected, and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. The kitchen was clean and considered secure, daily and weekly cleaning schedules were in place. It was agreed that evidence in a scheduled plan of monthly cleaning would reflect the observed good standard. The building complied with local fire service with a report is imminent, and Environmental Health and Health and Safety requirements. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is adequate. The overall staffing coverage manages to maintain the expected levels each shift that was inspected, over a three-week period. Discussions with residents and visitors to the home also conveyed a very positive impression of staff conduct. The procedures for recruiting and appointing staff were seen to be much improved, with sound practice in place to ensure secure appointment of staff. Staff training was discussed and was found to need a review of the arrangements in regular training and supervision. Staff training records need to complement the effort placed into staff training. EVIDENCE: There were 27 residents in the home on the day of the inspection. Off-duties were provided and examined; staffing levels were seen to be satisfactory. The daily care staffing rota showed adequate balance between skills, experience and numbers to provide a good standard of care. Discussions with staff also confirmed their commitment to providing a quality service and their awareness of the principles of good practice. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 21 The staffing establishments were examined and found to be satisfactory in meeting the staffing notice. An average coverage was seen to be: a.m – 1 Senior 4 carers p.m – 1 Senior 3 carers N.d - 1 Senior 1 carer The catering, domestic and laundry hours were determined and found to be appropriate for the size of the Home, and the needs of the residents. It was felt that as the refurnishing programme continued that more domestic hours are needed. Observations of staff on duty conveyed a very positive impression of their competence and care of the residents. Three members of staff were interviewed, who confirmed the appropriate staffing levels, conduct and training of staff. Those spoken with on the day of inspection demonstrated satisfactory standards, and an infectious enthusiasm for their work. Several staff files were examined which showed a general consistency of general application of procedure in appointing staff. This involves a standard application form to assess and profile, two references taken and CRB (enhanced) checks gathered before a contract is offered to successful candidates. The thoroughness of staff selection has a significant effect upon the provision of cares to ensure protection of service users. All staff have a statement of terms and conditions, and the General Social Care Council code of practice has been secured and deployed to all staff. Staff training was discussed and was found to need a review of the administrative arrangements in organising regular training and supervision. 9 staff have NVQ level II, and 4 with a suitable First Aid Certificate. Induction was seen to be consistent, whilst training records identified the lack of a training programme to meet compulsory requirements for fire safety, health and safety, and hygiene issues. A review of the training plan would reflect the enthusiasm and performance achieved on training. The Care Manager was strongly advised to obtain the Mental Capacity Act 2007 guidance, and to instigate a programme of training for all staff. There was evidence to show that a formal supervision process is in use, the Manager emphasised the commitment made by senior staff in offering on-duty practical supervision. A process to cascade the responsibilities throughout the workforce was advised. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 22 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): 31,32,33,34,35,36,37 and 38 The quality in this outcome area is good. This judgement was based on discussions with the Care Manager and her senior assistant, the examination of the home policies and procedures with regards to the effective management of the home, general observations during the process of the inspection, and discussions with residents, relatives and staff. There is a confidence apparent in the interaction of residents, staff and the Home’s management, that demonstrated a highly positive relationship that pervades throughout the Home. EVIDENCE: The Care Manager Annette Horton has demonstrated evident competence over many years in running Manor House, in establishing a solid professional policy The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 23 portfolio that has been implemented, to achieve a good standard of set aims and objectives. The inspector was impressed by the openness, professional and pleasing confidence in the observed interactions of staff, relatives and service users. The relationships were seen to be of mutual trust and respect. Appropriate risk assessments are in place for service users, through care planning and recording, staff selection and the general environment, these are up to date and accurate. Health and safety notices can be seen throughout the home. The process would be enhanced with a room catalogue of risk assessment to update the present room based risk reports. A full schedule of daily, weekly and monthly checks of all utilities ensure a well maintained home. The home has an open door policy and a commitment to equal opportunities. The Registered Provider, Jason Horton, presents a high profile in Direction and managerial involvement in the smooth running of the Home, delegating a wide range of management responsibility to good effect. The case tracking undertaken reinforced the effectiveness of service user’s involvement in their care and environment. The Management is committed to maintaining and improving the quality of the Home’s services. An examination of administrative, monitoring, planning and care records showed an organised and professional attitude to effective record keeping. They were found to be well maintained, accurate and up to date, ensuring that the service users’ rights and best interests are safeguarded. The Manager offered evidence of safe working practices including: - code of conduct, abuse awareness, first aid management. Training on a multitude of subjects was acknowledged and evidenced, although the plan needs streamlining. The health and safety of service users and staff are promoted with safe storage of hazardous substances, regular electrical PAT and servicing of electrical and gas appliances, and regulation of the water system, each record examined, and found to be satisfactory. The accident book was seen and found to be in order for staff, service users and reporting arrangements to Riddor. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 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 3 3 x x 2 3 3 The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP33 OP33 OP36 OP33 Good Practice Recommendations Provide a development plan for 2008/09 Develop the policy on the handling of abuse to encompass Safeguarding provisions. All staff to receive adequate supervision, 6 times a year Provide a staff training development plan for 2008/09, a training programme be established to monitor frequency of training. Secure all wardrobes to adjacent walls. 5. OP38 The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 26 6 OP16 A complaints book be established to address concerns, complaints and allegations. Secure access to the medicines store. Ensure monthly cleaning schedule in the kitchen is kept up to date. That senior staff attend Mental Capacity Act training courses. That a full unit risk assessment programme be updated. Ensure MAR sheets records are accurately dated That the extra drug trolley be secured 7 8 9 10 11 12 OP38 OP38 OP30 OP19 OP9 OP9 The Manor House DS0000069001.V355372.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection 1st Floor Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE 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. 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