Inspection on 25/11/05 for The Manor House

This inspection was carried out on 25th November 2005.

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

Other inspections for this house

The Manor House 31/03/09

The Manor House 10/09/07

The Manor House 02/02/07

The Manor House 14/12/05

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 Manor House, The The Manor House 6 Bawnmore Road Bilton Rugby Warwickshire CV22 7QH Lead Inspector Lesley Beadsworth Unannounced Inspection 25th November 2005 09:30 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 Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Manor House, The 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 Mrs Monika Relton Care Home 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 Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager achieves the Registered Manager’s Award (Adults) by April 2006. 13th September 2004 Date of last inspection 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 to include up to six 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. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day from the hours of 10.30 and 21:00. The registered manager was present for most of the inspection. The registered manager and the other members of staff present, cooperated fully with the inspection process. The inspection included a tour of the premises, talking with the registered manager, staff and residents and looking at resident, staff and other records. Five residents and five members of staff were also spoken with. Two different inspectors made inspection visits to this home in close succession, Lesley Beadsworth on 25th November and Christy Wannop on 14th December. Both of these visits were unannounced. An administrative oversight led to these two visits happening within a short period. This report covers the first visit. The delay in producing this report is due to the long-term absence of the inspector immediately after the first inspection took place. What the service does well: The home is mainly attractively decorated and furnished. There are two sitting areas, which were clean and comfortable. The dining room is impressive and very well decorated with coordinating soft furnishings and table dressing and maintaining several original features. Bedrooms are comfortable and are of differing proportions and presentations. The home has a satisfactory complaints procedure and can demonstrate from records viewed that action is taken regarding complaints or concerns. Residents spoken with said that they knew who to speak with if they had any concerns and seemed confident that action would be taken to address them. The home has an activity programme and the details are displayed on a notice board in the home. Activities took place throughout the day of the inspection organised by the activity coordinator. Residents spoken with said that they enjoyed the pastimes and had plenty to do during the day. The registered manager carries out formal supervision with staff and is on target to carry this out at the required intervals giving the staff the opportunity to discuss the philosophy of the home, their individual work practice and their training and development. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The areas that could be better include Assessment of needs records must include History of Falls and Personal Safety and Risk. Care plans must include all areas of need and how the care will be provided to meet these needs. Menus need to take into account the likes and dislikes and wishes of the people living at the home and be based on consultation with them. The dishwasher in the main kitchen appears too small to deal with all of the home’s dishwashing. Monitoring of this needs to take place and any appropriate action taken to ensure that dishes are washed to Environmental Health standards. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 7 Steps need to be taken to ensure that residents do not run the risk of injury in the main kitchen as this is easily accessed from the main living areas. The home needs to monitor and record if residents are not taking sufficient food and fluids and action appropriately. The registered manager needs to ensure that there is sufficient brightness in the home for residents and that light bulbs are replaced promptly. The radiator identified at the inspection and in this report must be assessed to ensure that accidental burning cannot occur if a person fell against it. Guards must also be provided for the gas fires in the sitting areas to prevent accidental burns occurring. Portable appliances (electrical) need to be tested in line with the Electricity at Work Regulations 1989 to help control the electrical risks and safeguard people living and working at the home. The following infection control issues need to be addressed – - The laundry is very small and as a result there is no clearly defined dirty to clean flow. The room needs to be de-cluttered of an assortment of items and for drying or airing facilities to be improved. There are risks of clean laundry being contaminated by soiled or dirty laundry and of fire. - The home uses fabric towels and bars of soap in communal hand washing areas. This poses a very real risk of cross infection and therefore soap dispensers and disposable towels need to be in use in these areas. - Bins used in the communal toilets were open topped baskets but to maintain infection control and reduce the risk of malodour bins with lids, preferably that do not need to be opened by hand, need to be provided. - The carpet on the front staircase needs to be cleaned or replaced for reasons of infection control and for the comfort of people living at the home. - Insect screens need to provided to the windows in the kitchen to prevent contamination to food and utensils from insects entering via the windows. An insectacutor also should be provided to further reduce the risk. 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. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Details in initial assessments are brief and include most, but not all, of the necessary areas of need required for this standard. EVIDENCE: Four care files were examined. Preliminary assessments included most but not all the necessary headings of need required for this standard. History of falls, and personal safety and risk need to be added to the assessments. Details within the assessment record were brief and thus risked there being insufficient information for staff to meet the needs of individuals or to plan appropriately for their admission. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 Care plans are in place for all residents but not all the information the staff require to meet the needs of people living at the home are included. The systems for the management and administration of medication assessed at this visit are safe. EVIDENCE: Four care plans were examined. The information could be difficult and time consuming for staff to extract specific information they required to meet the needs of the residents. Two of the plans viewed did not mention needs that had been identified with the individual during the inspection. For example one resident complained of painful knees and observations made and viewing the nutritional assessment in his care file indicated that he had a poor appetite. Neither of these needs was addressed in the care plan. A further resident was said by a member of staff, and confirmed by the resident, to have frequent headaches and was seen to have a lesion on her face. Neither of these concerns was addressed in the care plan. These shortfalls have the potential to place residents at risk and the meeting of needs is dependent on good verbal communication and staff memory. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 11 A care file looked at included a ‘disclaimer’ from the home regarding the resident’s use of bath mats in his private accommodation. A risk assessment is needed in such situations to identify and minimise the risk and to show any action taken. Following the previous inspection the home was required to produce a protocol for ‘as required’ medication. Although this had not been available at this inspection the registered manager was able to forward a copy prior to the second inspection visit made in December 2005. Two care files included declarations made by the resident stating that they did not wish to be supervised when taking their medication. The registered manager was advised that a risk assessment would be needed regarding this, including any risk to other residents, and this was addressed before the end of the unannounced inspection. The remainder of the medication standard was not fully assessed on this occasion. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 12 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): 12,14,15 Residents enjoy stimulating and organised activity and occupation. Residents are able to make choices about daily living. A varied and nutritious choice of meals is offered to residents which are taken in attractive surroundings. EVIDENCE: The home has an activity programme and the details are displayed on a notice board in the home. Activities took place throughout the day of the inspection organised by the designated activity coordinator. Residents spoken with said that they enjoyed the pastimes and had plenty to do during the day. The care files indicated social and cultural preferences and residents and staff spoken with said that activities matched these preferences and the residents’ wishes. The registered manager advised that residents’ meetings and questionnaires are used to ensure that residents’ wishes are included in this programme. Other residents spoken with said that they got up and went to bed at a time chosen by them and were able to welcome their visitors at the home thereby maintaining contact with their family and friends. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 13 The home has a varied and nutritious menu over a 4-week rota and copies were made available. These menus are devised by the organisation for use by all of the homes owned by them, but whilst appearing interesting, nutritious and varied they have not been individualised to specific likes and dislikes of people living at the Manor House. There was no evidence to support that any residents had been involved in their planning. The main meal is taken at lunchtime and consists of three courses with two or three main course choices and two choices of desserts. The name of part of one of the meals was unfamiliar and no resident, care assistant or member of the catering staff knew what this was. Menus do not include breakfast or any mention of food offered after ‘supper’, which is served at 5pm. Staff advised that sandwiches are offered at 8pm and are also available as an alternative at any mealtime. The cook advised that breakfast consisted of cereals or porridge and toast each day and that poached or fried eggs are also offered on a day when a ‘heavy’ starter is not available at lunchtime. ‘Heavy’ starters include Welsh rarebit, assorted vol au vents, prawn and crab cocktail and egg mayonnaise. The evening meals are prepared and served by care staff. The meals need to include all meals of the day and reflect the preferences and wishes of people living at the home. The menus should be based on consultation with them. At the previous inspection the home was required to review their practice of plating of meals, as this was considered institutional. On the day of this inspection visit the food was tasty and well presented but was being served on to plates from a heated trolley outside of the dining room with nothing to indicate that residents had been asked what or how much they actually wanted. However prior to the second visit in December the registered manager advised that meals were now being served in the dining room to ensure that residents were consulted. Whilst staff were readily available to assist residents if this was required there were two residents on the inspector’s table who were not being encouraged to eat and who ultimately ate nothing at all in one case and very little in the other. Staff later advised that the residents had small appetites but this was not reflected in their plan of care and no advice was available to staff as to what action, if any, they should take. The previous inspection report recommended that food moulds be used when preparing liquidised meals but the registered manager advised that there were currently no residents taking a soft diet and therefore this recommendation is not carried over in this report. The meals are taken in a impressive dining room that was well decorated and had very attractive and coordinating soft furnishing and table dressings. However this room was not warm enough at the time lunch was taken. The kitchen was viewed after it had been cleared following the midday meal. The kitchen was generally clean although some areas of the worktops were well worn and chipboard exposed. This has a high risk of causing contamination and serious consideration should be given to their replacement. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 14 Windows in the kitchen, which were without insect nets, were wide open at the time of viewing. Whilst this was the winter season and therefore risk reduced, the risk of windows being open during the warmer seasons and the subsequent risk of insects entering, and then contaminating the kitchen and the food, is extremely high. Furthermore serving and cooking tools were hanging on racks exposed to the risk of contamination. Insect nets must be fitted to windows and an insectacutor should be provided to further safeguard residents from infection or disease from insects. The dishwasher provided at the home does not seem to be big enough for all the dishes at mealtimes. It is suggested that the registered manager monitor that all dishes are being washed to the standards required by Environmental Health. The kitchen is not lockable and residents are able to easily access this as the entrance is in an area used by them. A risk assessment needs to be carried out, and any identified action taken to protect residents from accidental injury if they enter the kitchen. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has a satisfactory complaints procedure that gives residents and visitors the confidence that their concerns are listened to and acted upon. There are policies and procedures in place to ensure that residents are protected. EVIDENCE: The home has a satisfactory complaints procedure and can demonstrate by records viewed that action is taken regarding complaints or concerns. Residents spoken with said that they knew who to speak with if they had any concerns and seemed confident that action would be taken to address them. Following the last inspection the home was required to include ‘whistle blowing’ in their adult protection policy and procedure and this had been carried out at this inspection. The registered manager advised that the home’s policy and procedure in respect of residents’ money and financial affairs did not yet include that staff must not be involved in assisting in the making of or benefiting from residents’ wills. However before the second inspection visit had been made in December the registered manager had forwarded a revised copy of the procedure to the Commission that complied with this requirement. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21,22,24, 25,26 Apart from minor shortfalls The Manor House offers safe, attractive and comfortable surroundings that are clean, pleasant and hygienic. EVIDENCE: The home is mainly attractively decorated and furnished. There are two sitting areas, which were clean and comfortable. The dining room is impressive and very well decorated with coordinating soft furnishings and table dressings and with several original features. Bedrooms are comfortable and are a variety of differing proportions and presentations. Two bedrooms had a slight malodour. Apart from this and the front staircase carpet being badly in need of cleaning the home offers mainly attractive and comfortable surroundings to the people living at the home. The home does not have the required number of one assisted bath to eight residents but as ten bedrooms have either a shower or bath ensuite in addition to the two communal bathrooms there are adequate bathing facilities. Only two bedrooms do not have an ensuite toilet. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 17 Following a relevant requirement in the previous inspection report the registered manager tests the call bell system each week to ensure that the residents have functioning facilities for calling for assistance if they need it. The registered manager has offered all residents a key to their bedroom unless their care plan or risk assessments suggests otherwise. The registered manager needs to make sure that the locks can be operated from the outside by staff if access is needed in an emergency. Not all bedrooms had the required minimum items. It is suggested that the registered persons carry out an audit and keep a record of the findings to ensure that all bedrooms have all the items listed in standard 24.2 of the National Minimum Standards or that individual residents either have their wishes recorded in their care plan or a risk assessment explains why an item is not provided. One shared bedroom has a fitted extractor fan in the ensuite bathroom that is excessively noisy and would not be conducive with comfort for the occupants. Folding screens were provided for the purposes of privacy in this shared room. Light bulbs in some areas were rather dim being only 40watt. The registered manager needs to monitor that lighting provides sufficient brightness for residents. Light bulbs were not working at the top of a flight of stairs, the ensuite bathroom in one bedroom and in the second floor linen cupboard. Both sitting areas have a gas fire, neither of which was guarded. There is a high risk of accidental burns from these heating appliances and guards must be provided. Radiators have had guards fitted but one by the dining room door needs addressing as the metal grid may conduct sufficient heat to cause burns if anyone fell against it. There were some infection control concerns in the kitchen and these are discussed in the ‘Daily Life and Social Activities’ section of this report. In addition there are the following concerns – The laundry is very small and as a result there was no clearly defined dirty to clean flow. The room was cluttered with an assortment of items stored, drying or airing. There are therefore risks of clean laundry being contaminated by soiled or dirty laundry. The risk of fire is also increased. The home uses fabric towels and bars of soap in communal hand washing areas. This poses a very real risk of cross infection and therefore soap dispensers and disposable towels need to be in use in these areas. Bins used in the communal toilets were open topped baskets but to maintain infection control and reduce the risk of malodour bins with lids, preferably that do not need to be opened by hand, need to be provided. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 18 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, Care staff have to spend time carrying out domestic and catering tasks. The home is not on target for fifty percent of care staff to have achieved NVQ Level 2 in Care by the end of 2005. The home has a robust recruitment procedure to protect residents from the inappropriate employment of staff. EVIDENCE: The home has only one domestic assistant who works five hours a day on only five days a week. The cook prepares and cooks the breakfast and main midday meal but care staff organise the evening meal. There are no designated laundry staff at the home. These factors mean that care staff carry out domestic, including laundry tasks, and also catering tasks in the absence of the domestic assistant or cook, which takes them away from time that needs to be spent with the people living at the home. On the evening of the inspection a newly employed member of staff was on duty but was working as part of the required staff team, rather than being supernumerary, and therefore unable to shadow an experienced member of staff. This would not give her the opportunity to learn the job adequately and would add to the pressures of the workload for the remaining staff. This would have an impact on the care provided and the safety provided to the residents. The home is not on target to achieve the target of 50 of care staff having achieved NVQ Level 2 in Care by the end of 2005 but as there were several Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 19 staff undertaking this training it is anticipated that this target would be met in 2006. Following the previous inspection there had been a number of requirements related to recruitment – a need for Criminal Records Bureau checks, Protection of Vulnerable Adults (POVA) 1st checks, and other health and safety checks. These requirements had all been addressed and the home now has a robust recruitment procedure. Evidence was available to demonstrate that POVA 1st checks are acquired and Criminal Records Bureau checks applied for before an appointment is made. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 20 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): 36,37,38 The home has a programme that offers staff appropriate formal supervision to support staff. The home’s records are stored securely to safeguard staff and residents’ confidentiality. There are some shortfalls in health and safety practices that are potentially a risk to residents and staff. EVIDENCE: The registered manager carries out staff supervision with staff and is on target to carry this out at the required intervals. The registered manager was able to confirm after the inspection that she had formally included the headings of supervision that are specified in this standard of the National Minimum Standards thereby giving staff and management the opportunity to discuss the philosophy of the home the employee’s work practice and their training and development. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 21 At the previous inspection the home was required to ensure that residents’ information records were kept in a safe location and these were located in a lockable filing cabinet at the time of this inspection. To further minimise the risk of these records being accessed by unauthorised persons the registered persons if the should consider a digital-type lock on the door of room where this cabinet is kept. Locking the door each time the room is left unoccupied is more likely to happen with this type of device. Some documentation related to health and safety was examined. Legionella and water storage temperatures records were viewed and registered persons need to ensure that they take steps to comply with any identified water temperature requirements. The fire extinguishers, passenger lift and hoists had been appropriately serviced. Portable appliance (electrical) visual checks were recorded to be carried out six monthly. It is also necessary to carry out an in depth visual inspection by someone with the appropriate training to ensure that the correct fuse ratings is used and that earth connections are satisfactory. Portable appliances need to be tested in line with the Electricity at Work Regulations 1989 to help control the electrical risks and safeguard people living and working at the home. Other documentation and records related to health and safety was not examined on this occasion. As previously discussed the kitchen is not locked and this could create a risk to residents if they enter the kitchen without supervision. It is suggested that an appropriate lock is fitted, for example a digital–type lock that is also easy for staff to lock and unlock, as described previously. As mentioned in the section related to care plans and with regard to bath mats, the registered manager must ensure that any hazard is risk assessed and appropriate action taken. Following the last inspection the home was required to ensure that staff working in the home participate in fire drills. Fire drills had taken place but there was no evidence to confirm that staff had attended. The registered manager was advised to ask employees to sign the records to demonstrate this. The registered manager informed the Commission that this had taken place after the inspection. The home was also required to provide a visitors book so that there was always a record of who was in the home for reasons of security and also safety, for example in the event of a fire. The registered manager has provided a visitors log but this is reliant on staff coming to the office to enter the arrival and departure of all visitors and runs the risk of omission. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 22 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X 2 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 3 2 Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1) Requirement The registered persons must ensure that all the specifications are included in assessments, that assessments include sufficient detail and that they are revised as a resident’s circumstances change. Care plans must be updated promptly as the resident’s circumstances change to include all the needs of that person. The registered persons need to ensure that menus are based on consultation with the people living at the Manor House and include their wishes and preferences. The registered persons must take steps to ensure the safety of residents with regard to their accessibility of the kitchen. The front staircase carpet must be cleaned or replaced. The registered manager must audit the bedrooms regarding the minimum items required in private accommodation and include in care plans or risk assessments the reason for an DS0000032248.V278322.R01.S.doc Timescale for action 30/04/06 2 OP7 15(2) 30/04/06 3 OP15 12(2)(3) 30/04/06 4 OP15OP38 13(4) 30/04/06 5 6 OP19OP26 OP24 12(1) 16 23(2) 30/04/06 30/04/06 Manor House, The Version 5.1 Page 24 7 OP25OP38 13 (4) (a) (c) 8 OP26 12(1) 9 OP26 12 13 16 10 OP27 18(1) 11 OP27 18 (1) (a) item not being provided. The registered persons are required to ensure radiators, and any other form of heating, are adequately guarded or have low temperature surfaces. Advice must be sought from Environmental Health regarding the correct practice for dishwashing and, following monitoring the practice at the home, the registered manager must forward evidence to demonstrate that this is complied with at the home. The registered persons must ensure that the following infection control issues are addressed – There needs to be a clear dirty to clean flow of laundry to avoid contamination. Soap dispensers and disposable towels must be provided in handwashing areas. Bins used in the communal toilets must have lids. Insect nets must be provided at the windows of the kitchen. Worn worktops in the kitchen must be repaired or replaced. Staff must be employed to avoid the use of care staff to carry out domestic, laundry and catering staff. The care hours used for these purposes need to be identified on the staff rotas. The registered provider is required to employ domestic staff in sufficient numbers so as to ensure that the home is maintained in a clean and hygienic state, free from dirt and unpleasant odours. (The timescale of 31/10/04 was DS0000032248.V278322.R01.S.doc 30/04/06 30/04/06 30/04/06 30/04/06 30/04/06 Manor House, The Version 5.1 Page 25 12 OP28 18(1) 13 OP38 13(4) unmet) The registered provider is required to devise an action plan to ensure that a minimum ratio of fifty percent trained care staff is achieved. Adequate Portable Appliance Testing (electrical) must be carried out. 30/04/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP19 OP26 OP37 OP38 Good Practice Recommendations The fan identified in the report should be repaired or replaced to minimise the noise to acceptable levels. An insectacutor should be provided in the kitchen to further minimise risk of contamination by flying insects. The Registered Person should consider the installation of a digit-lock to the identified door to offer practical security for records. It is recommended that the visitor’s book is accessible to visitors as they arrive and leave the premises. Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 Page 26 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 Manor House, The DS0000032248.V278322.R01.S.doc Version 5.1 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. 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