Inspection on 04/09/07 for The Manor House

This inspection was carried out on 4th September 2007.

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

The inspector 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 05/12/06

The Manor House 20/02/06

The Manor House 30/08/05

The Manor House 24/02/05

The Manor House 05/07/04

The Manor House 03/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Manor House, 37 Stafford Road Walton Stone Staffordshire ST15 0HG Lead Inspector Linda Clowes Key Unannounced Inspection 4th September 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, DS0000005017.V340013.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, DS0000005017.V340013.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Manor House, Address 37 Stafford Road Walton Stone Staffordshire ST15 0HG 01785 812885 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Richard Charles Britten Mrs Diane Isobel Britten Mrs Phyllis Jean Smith Care Home 33 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (33) of places The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2006 Brief Description of the Service: The Manor House is located on the periphery of the town of Stone, and is part of the complex known as Waverley Homes. The home is well located to provide good access to a local shop and post office and just a little further to the wide range of facilities available in the market town. It is registered to provide accommodation for thirty-three older people, 6 of whom may have a mental frailty. The home was extended some years ago and provides comfortable and homely accommodation on three floors. Access is facilitated via a shaft lift. The majority of bedrooms are for single occupancy with just two used as shared bedrooms, one of which has an en suite. Within the past year the home has had an area to the back attractively landscaped, including a water feature, raised borders and seating for residents to enjoy. Car parking facilities were available. The current fees were agreed under special contract with the local authority with the expectation that service users would pay a £25 per week “top up”. For those who were self funding there was a charge of £404 per week, which does not include extra services such as hairdressing, chiropody, toiletries which were all available at extra cost to the resident. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 5 The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection and inspected against the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. This was a key inspection and covered all of the core standards. The inspection of the home took place over a period of 7.75 hours and included an examination of records, service user care plans, personnel files and associated recruitment procedures, complaints files, health and safety records and a feedback session. As the registered manager was on leave at the time a subsequent visit was carried out to check statistics and procedures that were not available on the day and this took a further 2 hours. Questionnaires were forwarded to eighteen service users in the home and there were six responses. All were satisfied with the service they received at The Manor House. Additional comments made by service users have been recorded throughout this report. The home had returned the Annual Quality Assurance Assessment (AQAA) document that provides the statistical information contained in this report. The inspector identified that prospective service users were provided with the information about the home they needed to enable them to make a choice about whether the home suited them. There were care plans in place for each service user. However, these had not always been regularly reviewed and information was not always current. There were some concerns regarding the administration and timing of medication which needed to be reviewed. Service users indicated that staff were respectful and sensitive to their needs. There was a good activities programme with entertainment inside and outside the home. In the main the environment was well-maintained but there were concerns regarding the cleanliness of the kitchen. The passenger lift had been very unreliable but was working on the day and had recently passed its annual inspection. There were concerns regarding poor levels of staffing that were impacting on the quality of the service. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Care plans must be kept up to date. There must be improvements in medication procedures. The flooring in the kitchen must be replaced. There must be sufficient experienced and qualified care staff deployed to meet the needs of service users and bearing in mind the geography of the home. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 8 More care must be taken with obtaining adequate information during recruitment procedures to ensure that those employed are fit to work in the care home. Personal records in relation to people who use the service must be kept securely. 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, DS0000005017.V340013.R01.S.doc Version 5.2 Page 9 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, DS0000005017.V340013.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users receive detailed information about the home to enable an informed choice to be made about whether the service can meet their needs. People are able to sample the service before making decisions on whether to take up permanent residency. The home did not provide intermediate care so Standard 6 was not inspected. EVIDENCE: No requirements were made in this outcome area in the last inspection report. The Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager, identified that the Statement of Purpose was provided in each bedroom. During the inspection a copy was seen on the notice board in the main hallway. During this visit, one service user spoken with who had recently been admitted to the home confirmed that they had received a service user guide, had visited The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 11 the home and had attended for respite before making a decision to move in permanently. From information provided it was clear that a full needs assessment had been undertaken to establish whether the home could meet the individual’s needs. A social care professional, family and service user were observed reviewing one persons care needs with the service user and subsequently making a decision to stay permanently at The Manor House. A small random sample of service user files was inspected. There was no evidence to confirm that written confirmation was sent to the prospective service user by the registered manager that the home could meet their needs as required by regulation. It is understood that this procedure is carried out but a copy of the letter is not retained. A recommendation has been made that a copy of the letter is retained on service users files. (Recommendation 1) The last report clearly identifies that all service users had a contract covering their terms of residency. The contract was not, therefore, monitored during this visit. From information received it was apparent that service users admitted to the home for short respite periods were being accommodated in a shared room occupied by a permanent resident. A recommendation has been made that only permanent service users be accommodated in the shared room to uphold the privacy and dignity of the existing permanent resident. (Recommendation 2) The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were care plans in place for each service user, however, these had not always been regularly reviewed and information was not, therefore, always current. Service users were treated with respect and sensitivity. EVIDENCE: A small random sample of care plans was examined. It was noted that these had not been reviewed on a monthly basis in recent months. It was also noticed that records that should be filled in on a daily basis had been completed only spasmodically in relation to washing/bathing, bowels and, in one instance, bloods in the case of a diabetic. Several people told the inspector that staff ensured that prompt medical attention was provided and there were records of GP and Community District Nurses and chiropody services visiting the home. The record showed that the advice of the reablement team had been sought in one case. In two instances General Practitioners had visited following a request by the home and had asked for medical procedures to be carried out (one on 15/05/07 and another on 20/03/07). There was no subsequent record of the The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 13 outcomes of these tests or any actions to be taken by the home. In one instance, it was written in the notes that one service user had experienced a medical problem on a number of occasions, however, staff had not sought medical advice. One care plan showed that a service user was on a liquefied diet but discussions with care staff and the cook identified that this was no longer the case. The record also showed that the person should have Fortijuice three times a day but this was not prescribed by the General Practitioner and discussions with care staff found that this was not being administered. In order to meet the current health care needs of service users it is vital that care records are kept up to date. It is also imperative that the outcomes of any medical procedures are recorded in order that appropriate care may be delivered. Requirements have been made as part of this report in relation to these matters. (Requirements 1 and 2) The morning medication round took place at about 9.30 am whilst service users were taking breakfast. It was noticed that the medication for one service user was signed off before they had taken it and that eye drops that should have been administered had been overlooked. A requirement has been made regarding this situation. (Requirement 3) It was also noticed that the lunchtime medication round took place a little before 1 pm. A requirement has been made that a review of the timings of the medication rounds be undertaken to allow sufficient time between the rounds to ensure that medication is administered as prescribed and that other instructions such as administration before, with or after food can be observed. (Requirement 4). It was confirmed that senior care staff were responsible for the administration of medication and that each had received Safe Handling of Medicines training. A high number of service users were spoken with on the day and confirmed that they were treated with respect, sensitivity and dignity by staff members and this was observed throughout the day of the inspection. Six service users who responded to questionnaires indicated that staff listened and acted on what they said and were available when they needed them. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a comprehensive Activities Programme in place and service users made their own decisions on whether to take part or not. Daily routines were flexible and service users were encouraged to maintain family and community links. There was a four-week rotational menu to ensure that a balanced and nutritious diet was provided. EVIDENCE: There were no requirements made in this outcome area as part of the last report. Recommendations were made that televisions be rearranged in the main lounge and that teatime provision should be reviewed to allow residents to choose from a hot meal or sandwiches. Those service users spoken with on the day confirmed that daily routines in the home were flexible and suited them. The majority of service users took their meals in the two dining rooms on the day of the inspection. Cook was off duty and was being covered by the kitchen orderly. Lunch consisted of sausage, mashed potatoes, peas, carrots and gravy with a choice of rhubarb crumble, sponge pudding or stewed plums for pudding. At teatime there were fish fingers, chips and peas and a choice of The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 15 sweet. This would not appear to be a balanced and nutritious diet. Several service users on the day indicated that they considered the food could have been better. Upon checking records of food served it was not possible to identify which service users had taken the main choice or whether they had been offered an alternative. It is understood that each service user is asked what food they would like for the following day and the inspector observed this. A record was not kept of this information and it is recommended that the record of food chosen by service users be retained in order to demonstrate whether they have eaten the main meal or chosen an alternative. This will also be useful information in monitoring whether service users are having a balanced diet and is particularly useful information when monitoring specialist diets. (Recommendation 3) Six service users who responded to questionnaires expressed satisfaction with the meals at the home. It was noticed that it was routine procedure for the vegetables for the main meal to be prepared a day ahead. Potatoes and cabbage were seen in the refrigerator. However, these were not covered and the cook was asked to ensure that they were kept covered at all times. (Recommendation 4) A varied programme of planned activities was provided at Autumn House a nursing home that is located on the same site. Several service users confirmed that they attended bingo sessions and other social events at Autumn House and enjoyed the “change of scene”. One service user and one relative visiting the home commented that there had been no outings in the past twelve months. A service user who responded to the questionnaires stated “there are many activities to take part in, but I choose to take part in keep fit and singing only”. It is understood that there are plans to take approximately seven service users on the annual trip to Blackpool Illuminations towards the end of September/beginning October 2007. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives were informed about the home’s complaints procedure. Procedures and training were in place to ensure that service users are protected from abuse. EVIDENCE: No requirements were made in this outcome area in the last inspection report. The complaints procedure is outlined in the home’s Statement of Purpose and Service User Guide. Details were displayed in the hallway of the home. Service users spoken with said they felt confident about approaching staff and management with any concerns, knowing they would be listened to and dealt with. The AQAA document indicates that there had been no complaints received since the last report. However, one safeguarding referral has been made in the last 12 months. In the absence of the registered manager it was not possible to discuss this incident. This was followed up upon her return and found that an appropriate referral had been made to the local authority and CSCI and Protection of Vulnerable Adults team regarding the incident. The Commission has received one formal complaint raising concerns about the unreliability of the passenger lift, unpleasant odours, a cold bedroom and sloppy staff. The person who raised this complaint wished to remain The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 17 anonymous and agreed for the inspector to monitor the issues during this inspection. It was identified that engineers had been called out to the passenger lift on 22 occasions since the beginning of the year and in February and April it was out of service for several days. Maintenance work has been carried out and the records showed that on 26th July 2007 the lift had its 6-monthly inspection check. On the same date the LOLER certificate was issued which certified its fitness for purpose. On the day of this inspection it was noticed that there was a gap on the threshold of the lift on the ground floor. This was pointed out to the proprietor on the day as it was large enough for the ‘leg’ of a walking frame, shoe heel or walking stick to become lodged in and therefore presented a hazard. The proprietor agreed to fix this without delay. The proprietor also confirmed that the lift had been thoroughly overhauled by qualified engineers, a new motor and new internal doors had been fitted. The records confirmed this. The inspector noticed on her second visit that the gap had been repaired. The manager will, however, still need to monitor the integrity of the flooring in the lift to ensure it does not become a trip hazard. The proprietor and staff in the home agreed that this had been a serious problem. The proprietor stated that staff were not closing the internal doors correctly which caused the failsafe mechanism to stop the lift. It is understood that staff are now aware of this situation. It is the policy of the home that staff accompany service users in the lift at all times. There was a stair chairlift between the ground and first floor. Should this continue to be a problem the manager will need to undertake risk assessments taking into account the mobility needs of service users in bedrooms on the upper floors. The home was clean and there were no malodours. The allegation regarding the cold bedroom was difficult to substantiate on this inspection as it was a very warm day. It was noticed that the room had two central heating radiators. This will be monitored at the next inspection visit. None of the service users spoken with raised complaints regarding staff. Several without prompting confirmed that staff were very good and were kind to them. Policies and procedures were in place to protect service users from abuse and these were discussed with staff as part of induction training at the start of their employment. Protection of vulnerable adults from abuse procedures were understood by staff spoken with on the day. In the AQAA document the manager confirmed that there are incident forms available for staff to use and The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 18 that staff do report concerns. She also confirmed that staff received Abuse Awareness Training and a leaflet on the subject. Financial records were not inspected on this visit. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an attractive and comfortable environment. There were concerns regarding the cleanliness of the kitchen EVIDENCE: No requirements were made in this outcome area as part of the last inspection report. A tour of the environment was undertaken. All communal areas were visited together with a sample of bathroom/toilets and bedrooms. The home in the main presented as clean and well-appointed. Communal areas were homely and free from malodours. Bedrooms were personalised to individual choice. Service users spoken with expressed satisfaction with their bedrooms and the communal areas. Aids to daily living were provided by the home to promote independence. One service user who responded to the The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 20 questionnaires sent out as part of this inspection stated that they found “the fire doors quite heavy when trying to open them going to and from the toilet”. Another stated “Everything is alright and very comfortable”. There were concerns regarding the cleanliness of the kitchen and the damage to the kitchen floor that was ingrained with dirt. Discussions took place with the proprietor who promised to arrange for the area to be steam cleaned by the 07/09/07. An agreement was also reached with the proprietor regarding replacing the flooring. A requirement has been made in relation to this issue. (Requirement 5) It was noticed that rubbish was stored to the rear of the building (including old refrigerators and scaffolding) that was visible from some windows in the home and a recommendation was made for this to be removed. (Recommendation 5) A recommendation was made that consideration should be given to refitting the carpets along corridors where these are wrinkled. This was particularly noticeable on the 2nd floor corridor. This would reduce the possible trip hazard. (Recommendation 6) It was identified in the last inspection report in December 2006 that the home was experiencing problems with the shaft lift. Comments have been made regarding this matter under the section headed Complaints and Protection as this was raised as part of a complaint. The lift was in full working order on the day of the inspection but clearly the home will need to monitor this situation closely for the benefit of the people who use the service. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. From information provided it was considered that there were insufficient experienced care staff to meet the needs of the people who use the service. Insufficient information had been obtained regarding care staff who had recently been recruited. EVIDENCE: No requirements were made in this outcome area in the last report. A recommendation was made that the home should consider ways of improving staff retention as there had been a high turnover of staff during the previous twelve months. From the statistics provided in the AQAA document it would appear that 3 staff had left the home since the last inspection which is a significant improvement On the day of the inspection there were three care staff on the 8am – 2pm shift instead of four. From an inspection of the rotas it was identified that there had been one care worker short on the morning shift the previous day. An inspection of the rotas for week beginning 27/08/07 showed one carer short on the morning shift each day Monday 27th to Saturday 2nd September. There was one carer short for the afternoon shift from 27th August to 2nd September. One carer had to be “borrowed” from the sister home Autumn House for two hours on the afternoon of Friday, 1st September and an agency Carer was used to cover each of the afternoon shifts on Saturday 2nd and Sunday 3rd. It is understood that there should be three waking night staff on each night but the rota showed only two on 27th, 29th 30th August and 2nd September. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 22 Bearing in mind the geography of the building which has service user bedrooms on three floors and the dependency levels of users which was stated to be six who were independent and twenty-two who needed one staff member to mobilise, it is not considered that there were sufficient care staff on duty to meet the needs of the people who were using the service. A requirement has been made as part of this report in relation to this issue. (Requirement 6) The files of the last three care staff to be recruited were inspected. None of the applicants had given a full employment history to give an overview of previous experience. One did not have references from a previous employer providing two character references, one from a relative. One had only one reference from a previous employer but this was not dated. There was no copy of birth certificate and passport in any file. One carer had poor English language skills. A police check had been obtained for all three applicants, although those applicable to foreign nationals covered their stay in this country only. It was noted that one police check was dated 24/07/07 but the carer had started in the home on night shifts 06/07/07. It was also noted on one CRB that concerns were highlighted that had not been divulged on the Job Application Form which had resulted in the employee being formally interviewed by the manager and proprietor. In the absence of the documents outlined in the regulations which are the basis of a robust recruitment procedure, it would be difficult to form a judgement on whether the applicant has integrity and is of good character. It is imperative that the home ensures that the person seeking employment is fit to work at the care home. A requirement has been made regarding this issue. (Requirement 8) The AQAA document completed by the manager shows that there are 20 care staff employed in the home. Of these 7 have National Vocational Qualification (NVQ) Level 2 in Care. This shows that approximately 30 of staff have a minimum qualification of NVQ level 2 in care which falls short of the 50 (including agency staff) minimum ratio outlined in the National Minimum Standards (NMS). It is understood that six are presently undertaking the award. On the day of this inspection the cook was off duty and was being covered by the kitchen orderly who confirmed that she did not have a Food Hygiene qualification. A requirement has been made as part of this report that there must be sufficient people who when required to carry out food preparation and cooking in the home are qualified and competent to do so. (Requirement 7) On the return visit the manager stated that she had enrolled three staff on a Food Hygiene Course at Stafford on 23rd November 2007. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 23 The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 24 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): 31,32,33,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager was experienced and qualified to be in charge of the care home. Personal care records for service users were not stored securely. There was no evidence provided to confirm that regular supervision was taking place in the home. EVIDENCE: The registered manager, Mrs Jean Smith, had been involved with the home for 22 years and spent the past 15 years as the manager. She had attained the Registered Managers Award. Mrs Smith was on annual leave on the day of the inspection. The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 25 It was noted that the care records of people who use the service were stored in open boxes on a table in the office. The personal records of service users must be stored securely to promote confidentiality and to comply with the Data Protection Act. A requirement has been made as part of this report relating to this matter. (Requirement 9) It was a hot, sunny day on the day of the inspection and it was noticed that several windows on the upper floors were wide open. It is imperative that risk assessments are carried out, therefore, bearing in mind the conditions of people who use the service, to identify whether window restrictors need to be fitted to protect service users. (Requirement 10) Discussions with the registered manager identified that there may not be sufficient numbers of staff who were First Aid qualified. It is imperative, therefore, for a risk assessment to be carried out to ensure that an appropriate number of people trained to administer First Aid to the assessed level are deployed in the care home at all times. (Requirement 11) The records showed that fire training was carried out as required by regulation, i.e. six monthly for day staff and three monthly for night staff. It was noticed that a Fire Risk Assessment had not been carried out for each person in the home to ensure that their individual needs have been considered in the event of fire. Consideration should be given to mobility of service users and numbers of staff needed to assist service users, any medication they may be taking that might affect their ability to respond to instructions (e.g. sleeping tablets). (Requirement 12) It was also noted that the kitchen windows were wide open throughout the day and it is imperative that fly screens are fitted to promote food hygiene and to prevent the spread of infection in the care home. (Requirement 14) It was also noted that there were insufficient storage boxes to store opened packets of food in the kitchen pantry. Several were seen open on shelving. A recommendation was made for additional storage facilities to be provided. (Recommendation 7). The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 26 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 2 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X x 3 2 1 The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 27 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. 1 Standard OP7 Regulation 15(1) Requirement All people using the service must have an up to date, detailed care plan. This will ensure that they receive person centred support that meets their needs Where medical assistance has been sought and subsequent medical investigations have been carried out, e.g. urine, blood, outcomes should be sought and records updated to include any changes to service provision for individuals who use the service. This will ensure that people receive an up to date service that meets their needs. The record of medication administered must not be completed until the person has taken the medicine. This will ensure that medication is administered as prescribed and that an accurate record is maintained. It is imperative that medication is administered at times and in a manner prescribed by the individual’s General Practitioner e.g. before, with or after food. DS0000005017.V340013.R01.S.doc Timescale for action 14/09/07 2 OP8 12(1)(a) 30/09/07 3 OP9 13(2) 14/09/07 4 OP9 13(2) 30/09/07 The Manor House, Version 5.2 Page 28 5 OP19 16(2)(j), 13(3) 23(2)(d) 6 OP27 18(1)(a), (b) 7 OP27 18(1)(a) & 18(c)(i) 8 OP29 19(1)(a) (b) & (c) 9 OP37 17(1)(b) This will ensure that the health and welfare of the people who use the service is upheld. The flooring in the kitchen was damaged and ingrained with dirt. It is imperative that the kitchen, including the flooring is thoroughly cleaned by 07/09/07 and that the flooring is repaired/replaced without delay. This will protect the health and welfare of the people who use the service. Having consideration of the needs of service users and the geography of the home, it is imperative that there are suitably qualified, competent and experienced persons working in the home in such numbers as are appropriate for the health and welfare of service users. This will reassure the people who use the service that their needs can be met. It is imperative that there are sufficient people who when required to carry out food preparation and cooking in the home are qualified and competent to do so. This will ensure the safety of people using the service. No person shall be deployed in the home until the registered person is satisfied on reasonable grounds as to the authenticity of references received and that documents have been obtained in respect of the applicant as specified in paragraphs 1 to 9 of Schedule 2. This will ensure the safety of people using the service. Personal records in relation to people who use the service must be kept securely in the care home. This will uphold the DS0000005017.V340013.R01.S.doc 31/10/07 14/09/07 31/10/07 14/09/07 30/09/07 The Manor House, Version 5.2 Page 29 10 OP38 13(4)(a) & (c) 11 OP38 13(4)(c) 12 OP38 23(4)(c) (iii) 13 OP38 13(3) individual’s rights to confidentiality and comply with the Data Protection Act.. Several windows in the care home on the upper floors open fully. A risk assessment must be carried out, therefore, bearing in mind the conditions of people who use the service, regarding their health and safety. Where there are issues identified window restrictors must be fitted. This will ensure the safety of people using the service. A risk assessment must be carried out to ensure that an appropriate number of people trained to administer First Aid to the assessed level are deployed in the care home at all times A Fire Risk Assessment must be carried out for each person who uses the service to ensure that their individual needs have been considered in the event of a fire. Following the risk assessment appropriate staffing and equipment must be deployed/readily available in order to implement assessed procedures. This will ensure the safety of service users in the event of a fire. Kitchen windows were wide open all day and it is imperative that fly screens are fitted to promote food hygiene and to prevent the spread of infection in the care home. 30/09/07 30/09/07 30/09/07 30/09/07 The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 30 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 OP3 Good Practice Recommendations It is recommended that a copy of the letter to service users confirming that the home can meet their assessed needs (as required by regulation 14(d), is retained on the service user file. Consideration should be given to not accommodating service users admitted on respite arrangements in shared rooms with permanent residents. This will uphold the privacy and dignity of the permanent resident. A record should be maintained of the food served in the home and any alternative choice on each day. The record should identify which service users eat what food. Any food stored in refrigerators should be covered to keep it fresh and to reduce danger of cross infection/contamination. Consideration should be given to removing the rubbish at the rear of the building (including old refrigerators and scaffolding) which is visible from some windows in the home. Consideration should be given to refitting the carpets along corridors where these are wrinkled. This was particularly noticeable on the 2nd floor corridor. This will reduce any trip hazards for service users and staff. Additional storage facilities should be provided to ensure that opened packets of food are not left on open shelves in the pantry area. 2 OP4 3 4 5 OP15 OP15 OP19 6 OP19 7 OP38 The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-46 Stephenson Street BIRMINGHAM B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI The Manor House, DS0000005017.V340013.R01.S.doc Version 5.2 Page 32 - 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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