Inspection on 24/08/06 for The Manor House

This inspection was carried out on 24th August 2006.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Manor House 07/08/07

The Manor House 30/11/05

The Manor House 06/07/05

The Manor House 25/10/04

The Manor House 08/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 The Manor House Whitton Road Alkborough Scunthorpe North Lincolnshire DN15 9JG Lead Inspector Janet Lamb Key Unannounced Inspection 24th August 2006 14:00 DS0000002816.V309268.R01.S.doc Version 5.2 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 DS0000002816.V309268.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 Adults 18-65. 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. DS0000002816.V309268.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House Address Whitton Road Alkborough Scunthorpe North Lincolnshire DN15 9JG 01724 720742 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Ms Shirley Dawson Care Home 12 Category(ies) of Learning disability (12) registration, with number of places DS0000002816.V309268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can only accept the specified service user, Mr PB, over the age of 65 years. 30th November 2005 Date of last inspection Brief Description of the Service: The Manor House is a large property in its own grounds in the village of Alkborough, providing care and accommodation to up to 12 adults with learning disability. There are single and double bedrooms on the ground and first floor and there is plenty of space within communal areas for residents to use. The costs of living in the home from July 2006 range from £300.00 to £897.00. The home has a mini bus, gardens with roaming fowl, and a courtyard for service users to use at will. A local village shop is within walking distance, and the town of Scunthorpe is a short bus ride away. DS0000002816.V309268.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began with the sending of a pre-inspection questionnaire to the home in late June 2006, requesting information on the service provided and the names of those service users living there, as well as the names and addresses of their relatives and any health care professionals involved in their care. Survey comment cards were then issued to as many of these people as possible, including service users, to obtain their views and opinions of the care provided within the home. Then on the 24th August 2006 Janet Lamb visited The Manor House, without prior warning and as part of this inspection. Several of the service users were spoken to and three were interviewed, but most of them were observed throughout the inspection. The Deputy Manager and one senior care officer were interviewed, and another senior care officer and care officers were asked questions throughout the visit to obtain particular pieces of information. The main parts of the house were inspected, as were four service users’ bedrooms. Care plans, risk assessment documents and some records were read and staff files and training records were seen. All personal and private areas and documents were only seen with the permission of the people they belonged to. What the service does well: Service users are well assessed and checked to make sure they fit in with everyone else before they are admitted to the home, and other people living there are asked if they think they will get on with them. Some service users have lived there a number of years, but all have learned to get on. One newly admitted service user said, “I came to look round before I moved in, to see if I would like it.” Service users have good care plans written out to show staff what care they need, and these are reviewed regularly. Service users enjoy making choices and decisions of their own and take risks in life if necessary, but only when risks are lessened. All service users enjoy good levels of activity, in the home or the community, and have developed good relationships with the staff and friends. Their rights to make decisions are well respected. The food given to service users is good and they can either have it prepared by the staff or they can assist with its preparation in the kitchen. Some of them enjoy shopping for food in Scunthorpe or the village. DS0000002816.V309268.R01.S.doc Version 5.2 Page 6 Service users are given good support with their physical, emotional and personal needs, and with the taking of medicines. If they have a complaint, then staff and management help then to put things right. If anyone harms or injures them, they can be sure staff will seek justice. Service users have a good environment to live in, are cared for by qualified staff in just sufficient numbers, and are protected by effective employment of staff. They are also protected from harm by good practice and regular checks on safety within the home. 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. DS0000002816.V309268.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000002816.V309268.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 only. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. People using the service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: The documentation for three service users was inspected, with their permission. One service user has been living at The Manor House for approximately 21 years. He could not remember ever having an official assessment done, saying “I’ve had a sleep since then,” and it is unlikely there ever was one completed. There is however, a current document called “Getting to Know You” and dated August 2003, held in his file, which shows information gathered by the home for the purposes of holding a formal review back then. This has been used to produce a more up-to-date care plan, which has been reviewed regularly since that date. Another service user was aware of her assessment and care plan documents held on file, but could not remember how long ago these had been produced. She too had copies of the home’s assessment “Getting to Know You” on file. A third service user has his placing authority assessment document held on file and can remember having had his assessment done with a social care worker. DS0000002816.V309268.R01.S.doc Version 5.2 Page 9 The Deputy Manager and staff on duty confirmed the process undertaken when a new service user is introduced to the home, explaining that the home’s assessment can take several days of observation and encouragement, and that the Manager visits the service user before the placement begins to determine whether or not, in her opinion, they will fit in with the rest of the people living in the home. All prospective service users receive a statement of purpose and a service user guide. DS0000002816.V309268.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy making their own decisions in life, with risk assessments being put into place where necessary. Care plans are well reviewed as requested or in line with the requirements of the providing authority. EVIDENCE: Care plans are in place for service users and evidence of them being reviewed every six months or if the service user requests it is available in files. Care plans contain evidence that service users or relatives have been consulted and where possible service users sign their documents. Service users spoken to confirm that review meetings take place with the involvement of themselves, their relatives, care co-ordinators and key workers. They explained that they usually write to invite people to reviews. Care plans meet the requirements of standard 6. Service users confirmed they make decisions within their daily lives, with or without support from staff and advocates, and acknowledged they do take risks. Two were keen to point out that they make up their own minds about daily living. One said, “we make our own minds up, I go shopping in DS0000002816.V309268.R01.S.doc Version 5.2 Page 11 Scunthorpe when I like, I do gardening and am part of a discussion group and also the Partnership Group at Scunthorpe Hospital.” The other said, “There’s nothing else I want to do or change, I like the way life goes. I sometimes go out on a bike ride, there’s no risk. I just go when I want to, there’s no need for a risk assessment.” Risk assessment documents were seen in files for other areas of service users lives though. Daily diary notes show the support service users receive and the decisions they make about their daily lives and activities. Two service users complete their own diary records each day. One was observed doing this on his return to the home later in the afternoon. There are policies and procedures for staff to follow on service users’ finances, privacy and dignity, independence, choice, rights and responsibilities, and risks etc., which all enable staff to encourage independence and self-rule. There is a policy on service users going missing unexpectedly, which was tested on a couple of occasions in the last twelve months, and a good outcome for the service user involved was swiftly achieved. Risks for his safety were high, but the management and staff acted promptly in obtaining the assistance of Police, and informing relatives and the commission. Discussion with staff confirmed service users make decisions and choices, sometimes with advice or support but always as a result of being informed of the options, consequences and risks. DS0000002816.V309268.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. All service users enjoy satisfying lifestyles of their choosing, with support from staff where necessary. EVIDENCE: Service users spoken to are very satisfied with the lifestyle they lead. Nearly all of them have different places to attend in the daytime, involving work or activity placements. Those remaining in the home pass the time of day in other ways. These may be gardening, helping to cook, tidying their rooms, watching television, styling their hair, setting table and clearing away, knitting, listening to music, playing computer games, and going out in the home’s bus to do food shopping or just for a ride. All of these were either observed taking place on the day of the visit or were discussed with service users. Service users sometimes use the village facilities; local shop and pubs are used by most and one service user visits the church every Sunday with local people. The nearest town is Scunthorpe and services are accessed there, via the home’s bus or a service bus. DS0000002816.V309268.R01.S.doc Version 5.2 Page 13 Some service users spend weekends away with parents or other family members, and others receive visitors in the home on a regular basis. Contact is maintained with relatives via the office as well, for the purpose of informing relatives of illness etc. Service users spoke freely about their relatives and the satisfaction they get from the contact they have, young nephews and nieces being the subjects of much conversation. Service users also spoke about having their rights upheld in respect of independence, individual choice and freedom of movement. They were observed using communal areas of the house at will and they and staff confirmed some of them have keys to their rooms. This is only if service users have been risk assessed and considered to be safe holding their own keys. Staff are vigilant about ensuring service users do not enter each other’s room unless with immediate invitation. Service users are satisfied with the way they are consulted about their lifestyles. One said, “We have residents meetings when we want to change anything or something needs discussing.” Another said, “We get asked about stuff. I just wish they would get on with the bungalows; nothing’s been done for over a year. We get promised things and they don’t get done.” The home is to be extended by building some independent living bungalows in the grounds and service users are anxious for the opportunity to move into one, thus increasing their independence and self-rule. Service users were observed asking for a hot or cold drink at all times of the day, and those able to helped themselves. They discussed what they like to eat and clearly know their favourites. They explained that they have made likes and dislikes known over the years and when staff are preparing meals for them they know what they will or will not try. Menus are compiled according to healthy options and the main meal of the day is provided in the early evening. Sometimes service users help with meal preparation and most of them take their turn to clear away and wash the dishes. There were no adverse comments about food provision from service users. Evidence was seen in care plans that all of the above issues are taken into consideration for individual service users. Diary notes showed when contact takes place with family and friends, where choices are made, and when service users engage in community or home based activities and interests. DS0000002816.V309268.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy a good level of support with their health care and personal care, and with self-administration or administration of their medicines. EVIDENCE: Service users have a range of different needs in respect of personal care, some needing no assistance and others requiring every assistance, and this is provided to them according to their wishes and preferences wherever possible, in a flexible but consistent way. Three service user said they were happy with the help they receive, one commenting that “There’s nothing I want to do or change. I have a care plan but I don’t really bother with it, as staff just help me if I need help.” He was able to make his own decisions in life and presented as being contented with the support available. Another service user was observed expressing gratitude for the emotional staff support when he put his arm around a staff member and said, “Oh you’re all lovely and shiny.” Care plans show detailed care for those needing high levels of support, and some service users were observed receiving assistance, not of a personal nature, but that aided their independence and boosted their self-esteem. One service user was pleased to have her hair washed, dried and braided. Other DS0000002816.V309268.R01.S.doc Version 5.2 Page 15 service users were observed making their own drinks, having a cigarette, watching television, assisting in the kitchen etc. Staff provide advice and support to service users on health related issues, and encourage them to be responsible for their safety and welfare. Specialist medical advice and care is obtained as necessary and details are recorded in case files. Service users spoken to were satisfied with the help and assistance they receive from staff when ill. One service user said, “I broke my arm, but it’s better now. I just tell the staff if there’s anything wrong.” No service users self medicate but one does self-administer insulin injections using a dosage pen. He said, “I do my insulin and blood. Staff don’t touch that. I give it twice a day and am used to it now.” Another service user said, “I am happy with the way it (medication administration) works and the staff hold it in store for me.” Medication administration record sheets were seen and showed accurate information of medication held and administered. Records held on medication administration showed there is a good audit trail, of stock controls, procedures and practice concerning administration and returning of medicines. Storage of medicines is satisfactory, but could be more secure if in a designated medicine cabinet. There is a double locked facility for controlled drugs. Staff undertake training in medication administration with the company and some are due to complete a refresher course in October 2006. DS0000002816.V309268.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and relatives access effective and efficient complaints and protection systems within the home. EVIDENCE: Prime Life plc has corporate complaint and protection procedures, which are made available to all service users via the statement of purpose and service users’ guide. They are also in picture format for anyone requiring this. Staff are well aware of the procedures in the event of a complaint or an allegation or suspicion of abuse. Staff complete training with the company in handling complaints and dealing with abuse and also cover vulnerable adults training within the Learning Disability Award Framework course that they follow on starting the job. There has only been one complaint in the last 12 months, according to the information received on the pre-inspection questionnaire, the record held in the home and staff explanation. Service users spoken to felt they could easily talk to a staff member about any concerns or worries they may have, and expressed the view that there would always be someone to speak up for the more vulnerable service users in the home: a staff member or one of the service users. They know about the complaint procedure and said they would tell the Manager if they wanted to complain. Service users’ finances are protected from abuse by ensuring practice follows written procedures and guidelines. Most service users rely on their finances DS0000002816.V309268.R01.S.doc Version 5.2 Page 17 being looked after by an appointee from another home within the company, and most do have personal allowance held in safekeeping. Two service users were asked about money held for them and both were satisfied they could access funds readily when they requested it. One had been in the home for some months now but still did not have his benefits sorted out. Service users felt they made their views known on a daily basis and issues rarely became serious or required the formal complaint procedure being put into action. They also explained about holding service user meetings to discuss any changes or issues as they arise. One service user pointed out that the only issue at the moment is the slow progression of the home extension: bungalows in the grounds. He said, “They want to get a move on with the bungalows, nothing has been done for over a year now. We get promised things and they don’t get done.” His comments intonated frustration more than complaining. Other service users were observed making representations of a daily nature to the staff and relationships presented as comfortable and professional. Staff spoken to confirmed there is a good procedure for making complaints or alerting management to concerns of abuse etc. and both had been used in the past. Whistle blowing is understood and has also been used. Records are held to show how complaints and allegations are handled. The home also has a compliments book, which contains thank you letters, cards etc. DS0000002816.V309268.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy a good level of cleanliness and hygiene within the home and the fabric of the building is well maintained. EVIDENCE: A tour of the communal areas of the home and viewing of three bedrooms with service users’ permission revealed the house to be suitable for its purpose, clean and comfortable. The lounge and dining room have had some redecoration and refurbishment since the last inspection. Service users expressed satisfaction with the accommodation arrangements and with the fabric of the building, although one jokingly said “My room’s a mess, don’t look at it.” It was personalised, full of videos and games, and very organised. This was a double room with en-suite bath and toilet. Another service user was proud to show off his private space with en-suite toilet. A third service user has highly personalised his room with his own furniture, collectables and equipment. Most rooms meet the requirements of standard 26, but where they do not there is a signed agreement with the service user to say certain items of furniture are not required. Some service DS0000002816.V309268.R01.S.doc Version 5.2 Page 19 users have keys to their rooms, but others risk assessed as unsafe to do so do not. The house is satisfactorily maintained, decorated and furnished. One of the four rooms seen had some malodour and special arrangements and risk assessments are in place to aid the service user and ensure safety. The laundry is well maintained and meets the requirements of the Water Supply (Water Fittings) Regulations 1999. Service users are encouraged to do their own laundry if possible, two of those interviewed confirming that doing laundry is part of the chores they undertake. DS0000002816.V309268.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from good recruitment and selection of care staff and from a well-trained staff group in respect of mandatory training courses and qualifications. 54 of care staff hold the appropriate NVQ qualifications. EVIDENCE: The company has a robust recruitment and selection policy and procedure, which proved to be used on viewing staff files. Staff also confirmed the process of recruitment and explained that service users are met and spoken to as part of the interview. Service users give their views on the suitability of interviewees. One confirmed he had been part of the interview for one of the staff. Evidence that identity details required in schedule 2 have been seen is held in files. Staff training opportunities were discussed with staff and training files showed details of courses completed and certificates obtained. Of the fifteen staff working in the home eight have achieved or are completing NVQ level 2, giving the home 54 of its staff with the required qualifications. Discussion with service users revealed some of them are aware that staff undertake training and two of those interviewed confirmed that they had also completed the company’s fire safety training. DS0000002816.V309268.R01.S.doc Version 5.2 Page 21 The home’s roster was inspected and staff were asked about staffing levels as evidence of the satisfactory levels of care hours being provided. Information provided showed five service users receive one-to-one care at some point in the day or night, and although the roster did not appear to show the staffing to cover these hours, discussion with the staff revealed that the hours are carefully used throughout the day and night to ensure all five service users do receive their allocated one-to-one time, but not all at the same time. Evidence showed that one-to-one hours are satisfactorily covered, with four staff on duty each shift and two staff throughout the night, when calculating the care hours on the Residential Staffing Forum for 11 service users, only one with medium dependency and ten with low dependency. DS0000002816.V309268.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from having a qualified and Registered Manager in the home that maintains consistency of the service. They are provided with a company indication of whether or not the service is good by means of the quality assurance system. They also enjoy protection from harm under the home’s health and safety measures in place and the practices carried out to maintain service users’ and staff health, safety and welfare. EVIDENCE: There is a qualified and registered Manager in post that continues to provide consistent and effective management of the home. She undertakes mandatory training and refreshers along with the staff, and runs the home in the best interests of the service users. Standard 37 is met. The company carries out a quality assurance system, which involves surveying relatives, GPs and other health professionals and also takes into consideration information received within care reviews from service users and relatives that DS0000002816.V309268.R01.S.doc Version 5.2 Page 23 are invited to reviews via a letter. But the system does not directly include the staff within the home. They are aware of the quality assurance system, but are unable to state what the process involves or when surveys are carried out, etc. An annual collation of information is provided in a report, and although there was one available for The Manor House for the year 2004, there was no report for 2005. Nor has there been a report sent to the CSCI on the review of the quality assurance systems in use, as required in regulation 24. Standard 39 is not fully met yet. Health, safety and welfare of service users and staff were sampled through checking of fire safety records, maintenance certificates and documents, and by viewing the kitchen and outdoors areas. Service users were spoken to about taking risks and undertaking chores in the kitchen and outside, and they were aware of hazards and the risk assessments in place to reduce risk, but they expressed the view that sometimes risk assessments are not necessary. Fire safety checks are carried out according to the requirements of the local fire department, and all of these were carefully checked and a new detection system put into place last year following a fire in the home. Fire safety checks continue to be carried out and recorded satisfactorily. Staff and some service users receive mandatory fire safety training. Evidence of this was seen in files. A requirement was made at the last inspection for the company to provide a copy of the home’s electrical safety certificate, but information obtained via a colleague from the Health & Safety Executive reveals there is no requirement for the home to have an electrician’s safety certificate, but the provider must ensure the home is safe. Gas safety checks were carried out in February 2006. Information was requested on the testing of legionella in the water system, and evidence was seen in the form of a record that a test had been carried out in April 2006, but there was no documentary evidence from the person or company carrying out the test to support this. A copy of this document was requested within the week and if not made available then a requirement would be made on the inspection report. Standard 42 is met, but evidence to confirm the legionella testing is still required. DS0000002816.V309268.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X DS0000002816.V309268.R01.S.doc Version 5.2 Page 25 No 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 YA39 Regulation 24 Requirement The Registered Provider must send a copy of any report in respect of reviewing the quality assurance system to the commission. Timescale for action 31/01/07 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 YA42 Good Practice Recommendations The Registered Provider should obtain evidence that the water supply has been tested for legionella and maintain a copy of the evidence in the home. DS0000002816.V309268.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000002816.V309268.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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